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■■ixi>w or IKR kOlAl. OOUAOB or rziuoiun ; pbthcuk to hh numrn tsi una of ' 
muAuai ; taniouH to rax bavt LoaDoN OBtLDTiW BosmAi, akd to iki 




56 & 58 Lafaybtite Place 

OorwMiOwi, 1884, 

1 Y r^ 


Sir :2lnbrctD Stark, Bart., ^.19., 




It was not without heaitAtioii that the author ooufsentdd to the pro- 
posml made to him by Meaars. Wood & Company, of Xew York, tliat 
ho shoaJtl vrite for thorn a. completo Treatise on tlic Di8cas>es of In- 
bacy Slid Childliuod. The lengtti of time whicli wmild bo required 
fnr the completiuii uf a taak so coneidcrahte, luicl, (!»{K>(!iiilly, tlio knowl- 
edge that maDy oianiials of varying merit were already in the field, in- 
disposed him to attempt a work wrhidi mtitit necessarily prove not only 
long but lalxjrioufl. Enconraged, however, by the reflection that hie op- 
portunities for studying these complaiat^t liad been abuudaut ; tliat in the 
OOOTMI of mare than twenty yearti he tiad ac^jiiircd a niaBH of valuable 
materi&L, and that of existing books few dealt with more than a [lart, 
of the subject, he tliought himself justified in believing that a treatise 
which midcrtook to disenn the wliole ettbjoct of diecaec in early life, 
aod to deal with the matter purely from a clinical 6tand-point, might 
not he without ita uses. 

Tlie oongtitntional pcenUnritica of childhood, and the weaVnc^ts duo 

to immaturity, so shape tie ooui-£o and gympluius of disease tiiat there 

are few uomplainis which do not aHtintne ttpeciul fitatures when present 

in the yonng. Coueeqnently the author has not hesitated to admit 

into hia pages descripliori* of every form o£ ilhiewt which i» capable of 

being influenced in its manifestaticmt by the early ag« of tlie patient. 

^^Thoec only have been purposely omitted which, like diabetes, present 

^'exactly the aanie charactore in the child that they do in the adult. 

^ Each aubjoct haa been treated as fully as the space would allow, 

^^^Dt nuuiy faults of omiitaion tnav, no doubt, be discovered. Tlie 

^B^IQthor, however, has striven to iiatifify all clinical rcquireniuDte, and 

»horo much must be loft out. that the book may be kept witliin rca- 

tootble linaita, hae been anxious to omit nothing of real value to the 


In the composition of the 1*^)1^(^4'^^ statisttcn has been gener- 
ally avoided, for nnlcss dealing with enormous numbers little that is 

tI fbefaob. 

trnetwortlij can be obtained from this method of inquiry. In fact, 
there can be little doubt that very erroneous inipresBions have been 
Bometimes derived from statietical calculation based upon an insuflScient 
number of cases. 

In order to increase the usefulnesa of the book, much care has been 
bestowed upon the sections relating to diagnosis and treatment. No 
attempt, however, has been made to include in the directions for treat- 
ment an enumeration of all the remedies whicli have been suggested 
for the cure of the several forms of illness. Such excees of detail not 
only fills the page with information often of doubtful value, but tends 
rather to confuse the reader than to instmct bim. Moreover, it gives 
to this branch of therapeutics an importance which, in the case of chil- 
dren, it does not always possesa In the case of a young patient, judg- 
ment in feeding and care in sanitaiy arrangements not seldom conati- 
tate the sole necessary treatment of the illness. Quiet, rest, appropriate 
food, and plenty of fresh air will often restore the health without the 
aid of physic ; or if physic seem called for, the remedies needed are 
simple and few. But whatever be the nature of the malady, and how- 
ever elaborate may be the medication required, the details of nursing 
should always take precedence of those of drug-giving. Keeping thi» 
truth in view, the author has been careful to give due prominence to 
the subjects of diet and hygiene ; and in the matter of drugs lias con- 
fined himself, for the most part, to recommending those only which 
experience has taught him to value, and upon which, therefore, he has 
himself been accustomed to rely. 

For purposes of illustration a number of concisely narrated cases 
have been introduced into the text. Most of these have been selected 
from the aathor'B case-booke, bnt a few are taken from the practice of 
his hospital colleagues. To these colleagues, for their kindness in 
placing their cases at his disposal, the author desires to express hia 
deep obligations. 

Oeobob Stbbxt, Hasovbr Squabb, 
J(m«, 1884. 


iTTBOmriTPORT Cbaftbo. , 

njliMa^Ml menllaritips nf ou-ly 1fr«, 1 -. raiitm of 8add«o 4i>atli, S ; oonra- 
bsiWBOei ' ; deflnttton of Intanc; luii earlv ulilldliooif, 5 : ctialcal «iamlD* 
atlon of infkDU. « ; liuiM-ctlgn of Uib (a«i, B ; iilLlttidu, S ; rty, M : »b- 
wnee of cnr. it ; thu pulwi, ; tlio HMpiraClntiK, 10 : the tpmpnrkliiru. tO : 
pjradB from rapid growth, 1 1 ; movonumta of itio rliest anil bfllr In 
BMtbiMg, 12 1 ijupcolion of lia moutb and throU. 18; ireatmeul, 14; 
f»m*d f«vdi»g, 14; n»duRlng l«mp«ratuf«, 13; balha, Itt; isWroal r«in- 
«diM, 18; aboM of aperlenia, 11). 

{lart 1. 


The eonUglona pdnelpio, 2L : morbid auatom^, 32; srm]itonu, *J3 : preH>rap- 
tlT« period, 3d: the nwdi, S:t; eaUrrfa. 211; airili«iiic niDUlM. 24; r«- 
lapaMiM: coiii{ilScallon«, S.'t ; Mqiialw, £0 ; diagaoxix, 2(1 ; prognoidi^ 37 ; 
Irtittwiil, 88. 


Bmonc OoeeoLA 

Sjmplons, W ; dlaeaoab, 91 ; trvatinimt, 81. 



CBAPTKE riL Fbvu. 39 

ftuiiHnn. 8S ; morbid anatomv, XI ; ffaiplom*. Hi ; rnvMicm, B4 ; Amjiti** 
■Ihw. 34; tlw n»h, iM; URipuratuiv, I^.l; iho dtaqtuiniatiTs ntaga. 36; 
luUgBUit («arli>t f«rer. 3*1 ; Mimpllratloiic aii<) w«]n«lK, ST; floarlttinimii 
rtwDinaUnu, S8 ; albumlnutia aoU iirumiv i.,viTipiuuiii, :ill ; lat«iit soarlst 
ltaTC>',40; diagnoaia, 41 ; pngami*.42: illiuilniUrc nana, 42 ; treMment, 

'Ckmss-pox ■« 

RrmplMna, 4f^ ; b-mpcratHre. 4ft ; ^atisreiioiiB Tarlc^lla, 4fl ; IrratntDiitt S(K 



BTmptomf and coniM, 51 ; proteotire value of TBoolnatlon, 6S ; mothod «rf 
raeobiatiiig, 5S ; ocoaaioiiKl seqaebe, 54. 

chafteb tl 

Bhauj-foi , 66 

Morbid KotXamj, 65 : ■jnnptonu, S6 ; Inonbatlon, 66 ; Inndcm, 66 ; oonopU- 
oatioiu, 69 ; T«rieti««, 60; dijgiuMis, 81 ; prognoeU, 62; tra»tm«iit, 8S. 


■UMPfl US 

Morbid uutomj, 65 ; BTmptonu, 6S ; iiumbatloii, 65 ; tempentim, 66 ; in»- 
tastaais, 66 ; deafaeM, 66 ; diagnoda, 67 ; traatment, 67. 


Cerebbo-spihal Pbtkh 68 

Canoation, 68; morbid anatomy, 68 ; ajmptoma, 69 ; nab, 60; nervoiu aymp- 
toma, 69 ; temperature, 70 ; paralTris, 70 ; oonmlsioiu, 70 ; Tariiities, 
71 ; form in fafanoj, 71 ; diagnoaa, 72 ; prognoaia, 73 ; treatment, 73. 

chafteb tx. 

Entebic Fbtsb 74 

Canaation, 74 ; morbid anatom;', 75 ; BTi&ptoms, 76 ; first week, 76 ; oeoond 
week, 77 ; third week, 77 ; digestire organa, 78 ; tbe nrine, 78 ; special 
eenwa, 79 ; tomperatnre, 79 ; doration, t)0 ; case, 80 ; mode of deatb, 81 ; 
relapses, 83; aeoondar; pjrexia, ^; conTaleeoenoe, 82; diagnoida, 88; 
prognoeis, 84 ; treatment, 85. 



Dipbtberia and cronp, 88 ; causation, 90 ; morbid anatomy, 91 ; cymptoma, 
93; mild form, US; Berere form, B4; albnminnria, 95; laryngeal dipb- 
tberia, 95; dyspsoea, 96 ; malignant form. 97; case, 97; secondary diph- 
theria, 9? ; complication?, 97 ; nasal diphtheria, 98 ; cntaaeoos diphtheria, 
98 ; inflammatory complications, 98 ; thrombosis of heart., 98 ; cardiao 
dyspncea, 98 ; apncea from laryngeal obstruction, 99 ; sudden death, 99 ; 
paralysis, 99 ; diagnoeis, 100 ; prognoeis, 103 ; treatment, general, 108 i 
local, 104 ; tracheotomy, 106. 



Causation, 109; morbid anatomy, 110; symptoms, 111; nub. 111; fever, 
111 ; oompUcations, 111 ; diagnods, 112 ; progaoeis, 112 ; treatment, 118. 


Whoopiko-cocgh. 114 

Causation, 114; duration of infection, 114; pathology, 114; nature of tbe 
disease, 116 ; symptoms, 115 ; the cough, 116 ; the whoop, 116 ; biemor- 
rhages, 116; complications, 117; ulceration of tongue, 117; bleeding 
from ears, etc , 118; digestive troubles, 118; nervoua accidents, 118; 
pulmonary lesiona, 119; Beqneln, 120f dlagnoeis, 123; prognosis, 128; 
treatment, 124 ; of oompUoatioua, 127. 



|]art 2. 



^C^^^^it^Oln, fiO ; htd BMding, 1S9 ; bad ntr, 130 ; nlntim to ajpliilii, UL ; to- 
IctioD tA tntMNuloaiii, 11)1 ; uMuro, IHI ; morbid mfttAniv, 1^; ii«ill«ft- 
tloD of boDCi, 133: MfUntiug of butivn. 13'i^ ohui^esin Intornnl arf*t», 
1S3: the urine, 134: »ir*iit(i of bone olian^et, 1IM : on llie cunuuU of the 
obMt cavilT, IM; Klation lo Mlfo-muliuiia, 130: "ooiikoiuUI riokeU," 
L US; t-jrajfiotat, 130'. divtunioii uf boii«, 1^7; ohwt, 1^; spiue, 130; 
W low boDM, 140; niwMl oatritioa, HD; oompIiottU'USS, US; djnguviib, 

ttMluMl, 144. 




OuHttien, 147: morbid anstomj-, 147: iiTiiiptnmK. 1114: (li« «oIil Hjiga, 14^; 
tlii» hot sU([e. 14^ : the nwnallng hIi^ii. l-Ut; *tii^«ui nfton ill ilavnlDiivd, 
148: mnperatnre. 149 ; orlno. 140 ; mall$cn«iit form. UO; AHipmlA. IW; 
htranUurU, 14u : clingtKwla, 14li : iirognoeii, IMI ; Utjalmunl, 131; lijpo- 
dennic Injeetinu of quiiiiim, 151. 



F^vqui'ticj ill obiIdr«ti, 15^, caaiation, 158; morbid anatomy, 154; tjrmtr 
toma, IM: inflaminntioD of joint*, jlVt ; poririardiug, 135; fownenaf its 
^fBptoiiu, I5A : t)lu«4nUlve oaw, ISA : onctwlonal Mverll/of ■jrinptonu, 
ilS6 ; jMrtoardial frIitUoD, IM ; effoaloB. IK : elevation uf b«art'i apttx, 
157; illtutratirv cwv. I'lT: itii|i[iurailvo pericjirdSli*. 137 ; uiicliH-anlilit, 
ISd : uloctotiTit i^iidociarilitlii. I-V1; plniriiiy, ITiK : illiixlrntivc cwin. l-tS i 

rneumonia, 159 ; h>~|i«r-pyr«xia. l^ ; rlioamatitim of atiiloinliinl irall, 
3!/; Qbruld uoduWa, ItiO ; duratiou. IGtl ; rtjLspMS. ItiO ; cliruiiiu iliuu- 
matio paiuB, llll ; 'littfiiuiiiii, ll! ; of p»rir«rditU, Itil ; undotiiirilitiH, lO'i ; 
alMf«tir« eudocirdltia, Hi: pro^noaU, 182; Meaolonftl dl«|ii>Mninoa «f 
MrdiM! tnurtnnra, 1U3 ; truumuui. lit!) : iialicylato of aoda, 104 ; impoi^ 
UDMornrt. IIU. 


rAXBatm QAxanitint. 

FttkolaQr, 106 : iDOrbid anst/iiny, I'lT : Bjciptoms. 167 ; dlaaemiDaWd form, 
lOoT UliutratlTe DaHi. 108 -. ganijraau til eictniEaiiiiia, Ktu ; drj aii4 mulft 
fwMles, IW ; of tuItb. 170 ; di«(piosis. 170 ; pro((iioaia, 171 ; troatment, 


part 3. 



■, m : benditarr ttndeiicy, 178 ; exciting mi>M«, 174 ; morWd «t- 
lianj, 174 ; caavatiiMi at gland*, 175 ; •jraiptonkt, ITS; rariL-t_v of thq 
Ivaiofui, 170 ; etrtanMOi abucmM. 177 ; dJMun of boiwa aud juints, 17V ; 
«tf tb« ifine. 178 i oueaMoa «f glands, 17V ; of oenrical glandi. ITV ; of 
IrobcIiUI Kl*i>d>. ttW: tU conaequ^uoeB, ISI : aathinatie attaaka. IBS; 
■llarsUoB in plijpalcal ligiiH. \ifi: of lut^Mtiterk- k'>">'*> 1^8; fla oouM* 
qacKMS, 184 ; dWi>oa>*> ^^ • Iftosaaaia, ibd ; Ui^aluicnlt 167. 



Acm TciiBiicnoau.. 

Tltree fomu, 1M>; eHmllfln, IM: hoMdiUr^ tntAttttj, IM; uwu vpodflo 
diaimiw, IDl : tli»tubefels bkeillun, IVI : inorliid nnatOBiv, IVI ; Ihamj 
gnnnlUton, IS2 : Uio gHuxt ohU, IttS -. Iudi; olmnKwi, lUs ; ImIou of In- 
toMini.-*, im ; ot th« (plwn, ItKt ; of lbs bUdd«r. IdS ; Dilur« of eheeqr 
mMUr, tll4 ; Hymptomft, IM ; gradual maset, IJU ; tompcnlnra, ItW ; 
ledeaia of 1«k>< If*^ '• ^°f^^ rrinptouui, IDfi ; in brain, Ifili ; fn liint;, tOfl : 
Uliwtratirtt CMC. 1116 ; in blkdaer, 107; la oUicr (»K*ns 11*7 ; Huiatlon, 
1(W ; di«gnD*i*, l&i; from gniilria ckturrli, IB8; frvm inTantilv nUopkjr, 
IVU ; of jtnlmonary ceaaulloktJoii, 10D ; of liib«rcli> of blAddi-r, lOB ; prog- 
no^, aiM ; tmtniml, WO. 




CMtMlloo, ■iliS; Indui'nce of tlio father Mid nrothtr, 903; Oolln'i Uw, 203 ; 
•cqturtHl •jr|iliilia, 'Mi ; tuvrbitl kiiAtuinv, !^ ; nBiKtioti of intioons Eann* 
bruiM, SM : of Mild orguUi, SM ; of'bonM, S06 ; two vu1«tle«, SOB | 
Puraffl Viom, aoo ; daulyUtfs, 207 ; ifroelfoii of bmat of Kkull, 907 ; 
onnlo^liw, !w ; KTinptomii. 3<)8 : •nnOling, SOtt ; mli. 'illB ; cxnnplindon, 
VX ; sirMtion of liur ana luilm '31il ; tliv rrj. 310 . iliiirksnlng of Ui« 
Imum,310; pMuAo-juurKlfiln, 2IU : Uw paralyala, 2lU i (citenl nntrltUnti 
aiUi r«l&p«w,311; M^gvlB, 311; dlkgnotla, 311 -. ivognoals, 319 i Inat- 

Port i. 





CnuMtiou. 'IW: morUd MMlomr. 219; fjmptvnu, 2U ; mUrganml of 
•plviii, ti~: ANieuiiK. 21T; tomporatim. "iW . hmiorrhapta, 318; eu- 
bfiK'ioi^'it of kIi>a*I<>> •l^i dbgiiuBia. SI'' ; from «uicriu fuvLT. 318; Iroin 
IjmplmdciitiiiM, 2IU; progiiuiln, 211t ; UvAtuuul, 319. 





FrHinmcT nf Impnrerishmpnl of t1i# blood In dilUroa, SSV ; nuotu for thii, 
^^l:'uiH'of the blw") III i>>ilHii'>i>, 'j:)0; oaitution, 3>W ; two ol«Moa, SflO ; 
inocMd anitlomv, iMI ; litlojisthio utcfnlm. 843; ■jnptame. S83 ; ooB' 
plvsioti. 3^; bnmtlilMmdM, 33:;; anirmfo momim, SbS-, ^plMAxta, SSS; 
hMKlvhe, 383: ■jnof^oDM of idiiimlliiu anvrala, SSS; diafnoKf*. 383; 
■n^iMMlc, 3M : tf«umonI. iM ; <ll*'l. 'iH4 ; aiimtion to jcmtmi bjrgltM^ 
SM ; InMi. 386 : uwolc, 3%) : coM-wator packing mi mumfft, 298. 




MMlUnaf •pldniocnlanivmont, S87; dmpic lijrpvrplwik, 23li'. morbli) anM- 
Vtaj, S3tf ; •.vmploiM, StM ; uiicmlft, liM ; uxIvum, SU8 ; Ui« blood. S^ ; 
fill 33U ; gulru-iut«HUti«l troubles, 3^; di^ngui, 340 1 proji&asta, 
940; trekUdvut, 24U ; kl>iu« ut mifrcunol fmtiaii*, !-ll. 


HxKOniiUA S43 

OuiMtion, 343 : norbfd aautomy. 242 ; Bjiiipt«iiii, HA ; (hroo gnula*, £43 ; 
harniDrrhigiM. 24a ; juint aSeoLioii, 244 ; dingiioais, &4fi ; jnogno*i«, S4R ; 
tratUMOt, 24&. 

PtxnmA i S47 

Two vacivtirt, 347 ; c»uaat)oa, ^4} ; morbid aiinlunir, 'iA7; \Mita\«gy, 348 1 
aymyUftiu, 'M>f ; vtu|>lion, :!41j ; illuflrativi.- can; 'iW; iiniim in limVM, 
S4U ; bMnocrhagio i>iit|iiir«, 240; vkfinut lia<mon:'Uiu;n«, 'i4U; pnvpnn 
ftwumUlnm. Stt; uiwiiiln, '^M) : t''m|>>>rnttir(>, 2M ; lllnfctrntivo mm, S90; 
radema, 300 : eer«bral lupcuitrrliagf, JM : L'ouviUsioiu, 21>1 ; o«arw, SU ; 
dlagnod^ fiOl ; prognowiH, 201 ; troatiuitiii, 2&1. 




QutBlimi, 2A3 : morbid antlorar, £34; pnrinntejil BStravualinn, 2A4 ; pkUial- 
ogy, &Vf 1 KTDHptonui. S.'ih ; luiiilfirDuiK, SlMt ; vwrlMnR, 250; pntMtilir, SfW ; 
MpM*tt0n of «piphviH.-s, S30 ; tha guioa, 3-^ll ; vtialiuxi*, 359 ; tqinpvrBtarv, 
US? ; cooxM, 3(7 -, 'dbignoeia, £97 -, prognona, 35ij ; tniMtoont, 2&t. 

. {lart 5. 


Oksksai. OoKanwiLiTiONa. 


SsclUbilliT of llie iiprToas ■yateni In «uly ltf«. 200 ; vbIu» of vorioaa Byxap- 
loms, 261 ; Niiitiit. 'Ail ; Brita«nn*u< '-^01 ■ ■■t^ta of lh« p(|pll*> 3St: da- 
llHuiDi 2^3; ilnnTBiiieeti, 3'(2 1 \oat of wnaciauauvae. 363; cWiiiiaa of 
l«mp«r, S6Dt : Ucmoun, 'JA'<i ; ipMiiM, S68 ; panljau. 2^ i aphotiia, !!!li3 \ 
rifiaitj, SIM; rctrndimt of 1i«mI, 9M ; ▼omiUog, 364; thv broutbing, 
atU; th* pniM, ddfi; cMMbraJ lliuli, SiK ; t]>« nrin«, 385; hjntoriaal 
■vnptoni*, 369. 


LuiTxnuarcs !» . 


CntaMhm, 9U7 ; uMKiaUea withrUkata, Sir? : nuliology, fiAB ; vxottiiiK eatua*, 
Ml ; iltnatntiTa «aM, 366; aTrnptnniM. 2419 ; dMnriptiMi of tbii»«1ziira, 
M) : daratioB of attaeks, 280 : lUiMlnttve cue, 2m ; tpurni limltKd m 
Klottls,9TO; oliamolers of the apasD In new-born Inranta. '2711: tnivdi' nf 
iaatb, tTO; ioMroentinn «f opiiloUla. 371 : dla^iuoalt. -.!71 : {trvpioala, 
m : traOmant, 37i ; ammonia, iTi ; cold baltiiiig, 379 ; frveh air, S73 ; 
iDtlf|iaamodMa, 373 ; loaUa, 3711, 





Dmallf Bnocliii<.>(l vlth larrBginniu Mridiilus kuiI rvflni ooamlikMia. 974 ; not 
nneominuu in tli« ftuliiMitu of rickvU, 274 ; iijrDiptciMa, 274 ; palB. S74 -. 
contraction of iiiunit<<, H4 : anikl utmu 2T4; inflnvHca of mantpoUtloii. 
275 : In aensllr bllnUsral, iii ; it seven'. penktB dnrli^ klMp. SfS : ku- 
aatlon uokOocitH), STU ; UUgnoala, STft ; ftugaaaiM, Vtt t UMUmeiit, 278. 




Oouimon daring thv Ant t«a jews of life, S77, caowdiaD, S78 i >jrinptQf»s. 
2TS ; 4«f«riplf(Hi of m pkr«xjna. in9 : drowcinei*, SVO ; U-iaporuv parkl- 
vste, SMl : MngaatioD of brtttn, 280 ; lUiutratlTa eu«, StHI ; diaj;aoid*, 2))1 ; 
Jnitn ettubml ennvubiotiB, 381 ; from ppilspBjr. 393 ; prc^oeU, 38S ; iti* 
flnenoe on train dwolppmeot, SfS : tjwituient, 384 : wanq hith., 394: 
clUonl, 2d4 ; nlUlle of uujrl, 283 ; aliiuuUuU, S86 ; tonic*, SdOi 


BnuimT , 

Osusulon, 380 ; herodiUkr; t^Bdcncy. 28S ; Icjarlra, 286 : a fit of cODTnUons, 
286-, iUuatrulr« ciae, 381}; pulialosy, S»7: aymplotan. 2iX-. t!fUtft» 
gnrioT, 2SS ; epilepsia cnitiw, iSS : a fit of cpilpptiu rvrtigo, 298 ', Ilia*- 
tnliT* enao, SKSI; (rfrqUflDov of utt&ck*, Stltl; a«CN»ati<m with «b«raA, 
2U4I ; itiagnmi*. SWl : from avn<!»i»', SUD ; from bnteriotl Btc, 29U ; pnw- 
tHwiti, Sfll : irMtniMit, an : 'gxnsriJ uupntlrm ta Wllfa. 381 ; diat, 3»3: 
the bromide*^ 298 ; strrotmla, S03 ; nitrite of amjl, 28IL 



Cautuilinn, 304 ; pnthnloitj, 394 ; aymptomx, SOfi -. headaiilM. 205; ImpaimMint 
<ti kU-M. '^'1 ; of 9tti«r eonaea, SUS ; illuFlpativ«i oaac, 3w ; pkilw i° limba. 
S1I6 1 ilhialraliv0 caiM, 31)6 I diaf^nuM*, 29<}; truatmrnt, »)7; atrycltuJa 
anil aigot, 397. 



OkBHtioUi 309 ; aa*i>oiati<ia viUi rboumatitm, 290 ; patlialoKr, 900 : variona 
Ouwriaa, 9M ■ >yTnptAinii, dOl ; diiwrdanKl umantnt*, 901 ; tooo-ordiiMi- 
tioB of relnnu^i- mnTvmsiit, dW ; alwpl w iiH u a. XjB : *»iiM)ry diclurtv 
aniws. ^03: h»niioliorea. 303 -. the urine, :W3: monul »tat«, 3U3: tem- 
pHiuturv. iltiU ; vralcnMa or louiiol*, ii(K4 ; liearl luiirniura. MM; eoanM 
awl ilumliQii. ill>4; dingiionlf. ;iOi; pr<ij,-uui>iH, illt4 ; trHsUneDt, SU6; hjr* 
giuno, SOS ; moral trcntiui-nt, dOI) : drnxN '^'^ i mowafiv, 304. 


iDIOPATniC Tbtajtts. 

ta infaou, tan In EnRland, 306 ; Mniallnn, 31)6 : tnlhiaBM ot mnera) niuuk- 
ftw.r oondltiona, MW : morUd anatotnr, 3Ult ; qmplMiUi oIO; diOGull; 
of Hwatlowiiw. 310 L atiffnvae of jaws, »10 ; ttmptrataro, HIO: altacla of 
xparm. :tli}-. tonic HstdilT, SIO ; llluMra(lT« oaae, 310; dunUloo, 311 i 
tvt«nu!i in older <<Kililrvii, :tl I ; !llii*lrallir« oaae, !.tll ; diagnaaia, 3I9; 
A«tB tlrvolinia {lOiaouiaf. :il3: pronoala, 31S ; ti-eitliBi^Bt, }{|:H : for««d 
f«*diof, 813 : Calabu boan, SiS ; i-lUorai, 313 ; Uluatraiira oaaa, 314. 




taraxmoK or the Bkaim. 

Clnulftlloa of bloact in i1i« bnilTi, :IIR: oiiuatlon, 310*. ttrofwtm, 318; nU- 
Hon to d«altllon, 310 : mid ruiiTulilaiia, Sl7 : UlnnW vmboKmtB, :<17 ; 
BHifUd aiiulocur. 317^ »jriii|itums, IIIA: Irriutiv*^ Matrit iinl nUnic«lljt 
iWMiKniwbli!, -Wfi ; tli« comaion farm, :ili^ ; itliMtrativit «ww, MH ; throin- 
Iwsia of oorobrfti uaoMs, 'H9 ; diwnotdK, KID ; prognofis, 320 ; UNlmBiit, 



Oulj comnoii in xtiU-boni chlldran, S33 : c«aaallou. 9ii ; w>m«UinM the r^ 
0iilt ot uiuiuIbb ot k cerebrAl ^rtcrj^, It'^.i ; umrtiid analumy, 322 ; nien- 
tpgeal tuBBorrbifft. ^83 ; ruicbr*! luf tnorrlio^r, ;U>i ; ciiiLiunf uiirui-utD, 
flStf ; •naptoms, 3^ ; of rnvninuvni Ltmorrbi^v, S'i4 . low Uiopor*- 
laf«, 1b4 ; irtiipftr utA eonvaUiauK, 'iSA ; n-twinblanoi' Ut tlniplv lu^nln- 
gWa, 89Si illaatr>tiT« oaw, »£V : F«T«bnl hii>m<uTl|^, 8fi0 ; llluetratt?* 
«U9^ 896 ; hamorrliaf e frum rupturv of kneurUm. S7T : Ultutnllra nsv. 
827 : dllgooiis, itttl : pruguusin. .T^t) : Uva-tinuut, 329. 


GKucrauL TcHoim. . 


CHBRjnr JIt-miocKPitAi.VB 340 

Oenbnl growth vMoally tabereulv, ^iiu : niurliid Knalomj, H^i ; nu-i«t1fia of 
growtlin, 331 i srmpioinK, !M1 ; hc-uducliii, lltU ; irouvubititui, !it2 ; Iim* of 
MmUiI Miw«, 392 ; oplitbiklu»Kc«}>ic nppoaruiocn, :)}m ; iliuMrativ* cmW| 
lS8i gliom&toun tiimouT, ;<:in ^ tnbnreDlftr growth, 935; illunliativ* (imm, 
335 ; two stagM ofi«n onon, A*>{II; lllDitrBtira cuo, S3tt ; M>r«belUr tntnoar, 
887 ; iihan«teriMI« ajmpUima, 337 : oUiur eeaU, 887 ; dli^noa^r •^3'' '• prog- 
nesfi. SS» ; trektmeut. 'Jliii. 

CiuMiou, 840; morbid imaloni/. 341 ; effecl ut preatiiro oti ttie brklu and 
•kull, 841 ; H}-nijili>iii.i. Mi ; diBUiilioti of aIcuU, Z4i : impivfvcL uiiUf- 
tlon, iMit; utt«lliK«tic«, 848 ; ticrvonn ByaptoiDa. 848 ; iUunlralirv c«m, 
848 ; the Mi)<dr«d tvtm, 844 ; tipont*t>«oua vYMtialivn of (Laid, 844 ; diag- 
v*0ia, 845 ; pto^oaU, 815 ; IroAtmont, 34Sl 


Omw Ain> m Ooksbqcexcea 


BsUulaB of InflAmnulon fr-^m tlio trm^tinn to t)\e ulcun cavltf, 840; pah- 
MLou, 846 : morbtd MMlomv, 3-17 *. aytajHorai, S48 ; esteii«IOD of Intlaiii- 
aMhra to tb« mcnbigMi. niS; jmrtitpnt mHuinnltit. 841); ii?inp»ratiir«, 
840: convnbiona, S4fl; illitntratiw aatn, A4I> ; phrvnilit farni,35A: de- 
tlrioDi, 3V1 ; hinperfttnrc SAO : thromlxists of tho evrobrni alniiM*, 351 ; 
•noaplwUlU. 'A'll ; oourulslone, 8rrl ; «tupor. Oil : panlj-ile, 891 ; illoi- 
tnll«« oastt, 353-, diksaMbi, SStJ ; progjiiowie, 3U -, tnsfctuuut, 3&i 




CoBHon at all a^ m of childhood, STA ; oauutlon, XiH ; uorlrid analom;. Sfifl ; 

SrapUrmn. .t'>7 ; ppmncmltorv, SST ; two form*. ."W" : primary mvotHRttia, 
7 -. tlim< ><«){>•■. H-i" ; nr»t nUqrf, aTjH ; n-iTiind Mao*", S^l* ; lliird kU^ 
801): damliiio of UlnefS. 941 ; fpcoiidary monintdlio, ^11 : romnioii In 
Infanls, 'Mil; UMxaalouA oaae^ 8ir.! ; dlaguoels, 803; Klustratlva CMB, 
SO ; prognofll^ 86S ; Iraaunent, 805. 




PAiui-rsje or -mii Pottrtn Dcra .,. 

GotUM «f lb« facial nvrr* In Cut Fkllopiui euul. SOT : UMiMtlon of tlM par- 
■l7«lB, 'tltT : iTinptaiM, 308 ; lUustnUivu caMt, 306 ; lUagnanw uid prQf 
uueik, iWll ; tieument. 31U. 


c SmcA.!. Paiulthu) 871 

1 ; tnorUd utUomy, XJi ; «yiniitainii, S7S ; onant, ^7S : pom- 
of Ihd panlyslB, 374; rnplrl limitiitiiiii of tlin pamlru'd ftma, 
ting of inuMles, STA : bUko of eonlrautlciu. 376 -. nMc^ianinu of 
mitiat, 875 ; diaguoais, 377 ; pragoeaU, ST* ; ireMUneiil, tfJ8. 

CantttiQu, 3;i ; morbid 

piAUttfriB of r 

374 : wading oi ihumum, 97a : buko oc eonirauuciu. mo ; mMiiiitnifU) 
Uw d«torm]ti«t, 875 ; diagiioais, 377 ; pragoeaU, 877 ; ireMUneiil, tfJ8. 


Si-ASMOUiu St-l^M. PAUAi.vnit<. 880 

Marbid anAtomv, ^(1 ; innBptenu, S8n ; ri^ldil^ of joiuU, 381 ; itlafumi>>, 
383 : progn<wl», 383 .'iroalmont. W3 



Ckimtinn, !^ i taathiA aiiiittmir, iW i e/iupluuin, 3tVi ; nnlui^isaixat of nna- 
clos, 3lJA -, proRTowivr ni'iU(ii4»ft, 38& i oooaaiuual ali\>phv of uuaolv, 886 ; 
ciMitracthHu, 986 ; counw, Sm ; diMtnoua, 8^7 ; prognoaiv, 9^ ; trwit- 
ii»-i>t, 888. 

lomct 380 

OkAMtlou, 880 1 narbid ■umtaniT', 3D0 ; daiwifiruitloii, !t.<>I -, *vtnprnins, SOI -, 
cNtlnlsm, S03 ; tlluidr»tfri!i oawb. 393 ; A«gtwa of meiibtl dcvclopinent, 
8M ; diapiiMiK, ■turi ; ili'vcloptncnt of Uio »i>iu«a iu the livnllby infAnt, 
890 ; pragDDiiui, :im ; tritainiHit, '467. 

(J art l>. 

CUAl'TKR 1. 


Pwitluti of the p^tluut duriu; «xftiulniitIoii. 809 -, Uupectlon, SM ; iilupn of 
tlM ohoal, 4(HI ; iitiivi>in«nto in rMplrjitiou, 400 -, n'trOflUou uf tlie olxit, 
40U ; «nlArt;<^in6nt, -lUI : paI|iAlion. 4U1 ; tomJ fivmitKH, -hH ; frietiun 
firamitun, 4(lt ; aitu uf a|Htx-tM«t ol hosK, 401 ; oiuimm »( itx iliKpUcatnf nt, 
403 ; l«rpl of t\w livBf Bnd Hplann, 403 ; pcroiwaon, 4<>2 ; >li<gT«e of re- 
etitancM, 403 : auscultMton, 4w ; condiictlan of aoiindxi, 404 


UvBTsams . 


111 -, Hrmptoma, 419 : d^spiKMt. 413 : oroupj' oan^li, 41'J ; t4>mpi>ral<u«, 
41S 1 IJIiiMrallve oaM*. 'lid ; (.'iirpn-p^dnl oonlT^RtloiiB, 413 : diagiiMl*, 4)3 ; 
progumia. 414: trwatment. 414 i iuljer«ular larjnglUi, 413 -, caimUtm, 
415; KTniptotiui. 4lt) ; illuntrktivH com. 410; diagiiuiua, 417 i ea»« ot 

41S 1 Ij'limrallve oaM>. -Hi : eii 

woguoaia. 414: trwatment. 4,, . ._ - —j-r. . -— . — 

415; KTniptotiui. 4lt) ; illuntrktivH com. 410; diagiiuiua, 417 i ea»« 
warlj grawtlutin larriix, 417 ; priM^iKitds, 4ld : trvatnioiit, 418. 






Oraafttion, 4ld : inorbM umlnm^, 411) : urnplolM^jIfl ; nttlinpnccH, 419 : nip> 
pnowd TfAet, 490 ; cU«tEii«citf, iSU ; pngno^ HI : In^utownt, 431. 


CnoDPOtra pHBmoKiA 432 

OknaMioB, 4?2 ; nMiirti of Ihu diwum, 423 : tannrtiinpii MCNmcIiirv, 43;t : tnnr- 
bld aualoiD}-, 433 : ^vniptomt, 4S4 ; ooiwt, 424 : UimpnrMiii^' 4S4 , fxiiifili, 
424 ; iiiiUKiilAr veikneM, 43A : iierrous aymptfmu, 43A : IlluatistlTS caae, 
4M ; lireaUiiDB, 434 ; |> it li«-re!<i<i ration r»UO( 43fi ; digvsilve ur);&Da, 4Sti ; 
ufiiMr, IW ; p3rrpxi«, 4^6 ; occaaionul drnpnouo, 437 ; pIi^Bical oigtis, 427 ; 
thoir Mat. 4Si ; tormJnations, AUt* ; t<.-fit)tulli>n, 4% : bImvui of thv limg, 
439 -, IfttnnI fAvat af [•ii*iitnoiii>. i2i) -, cminlicsiliins, 4Jlt> ; ]>ldAio plAorlHjr, 
4311: pi'ncikr'lills. 4KI)'. jaiiiiili(v<, 4:Ui : i.U»ifi)oiil»<. 4W; pTv^nnfia, 431 ; 
tr«ftliiLi-til. 4;t.i ; diet, i'^'i ; ri'dti«tiuu of ]>* rvxia, 433 ; I«pld IWtMng, 438 ; 
qobtliw. 432 : iralu« vt blncrdiuK. 4»a ; MituitlauW, 483. 




4S4 ; Bkorbid uiAlaaay, 434 ; •yroptoios, 4!ift ; alwava woondiir to 

Gbnnnu-j' dNUrrh, 4<1fi ; tomponitare, 486 ; niil«i>-r«cniMtkn rKtio, «J7; 
mthltiK, 4:17 : cntigh, 437 ; phxilonl ■Igtu, 4o7 ; tenniii atinii*. 4^(tf ; snb- 
■011(9 Goune. 43)< : uomptic&liona. 4<'I9 : diiurnoaii. 4illl ; fruui eroiipoua 
HuuiBanla, 440; «xa)u^n of tuIienTiilobin, 440; iwiit« ililkUtlou id 
branchi, 441 ; pnmaatia, 441; iriitRM-nt, 441 ; tiipi'd bathiug, 441; 
cgDntcr-irritition c^ olioct, 443; Miniiilsiiu. 44S ; diet, 442; omctin, 
448 ; iMti, 44.1. 



OaBMliotii 444 ; morbid UMtomr, 444 ; oh«ncl«reof ^ITiislon, 44n ; symptomB, 
44n ; DDMyt, 44S ; pjrazlN, 448 : palna 444i ; oomplexloui 440 ', eiaujrutaA, 
447; pl>_v«Iu>l ligiiti, 447 ; iiicpontiou, 447 ; p»Tciia>lou, 448 i MiMiiluiioii, 
44!) ; fri« bull -^>>u nil. 44U ; miowiiiuul n^iuptuuis, 440 ; apu-nlMiVVlia «TMtu- 
•tloQ. 43U; perforation of bronchua, 4r)(J ; illuirirativo cwa, 4G1 : ruivtioc, 
451 ; ptutic pli^iiriBy. 4*i2 ; l<)Ciilat«>d form, 4!>'2 ; tii buret] In lis form, 4.13 ; 
cntnplloulanx. 4X\ ; diaRtKKl". 4!iS ; from croiipoUB pimntnoTilii, iKi ; 
frwcnraUnhBl pneumonia, 454 ; frwn eollApaa of lung, 41)4 ; of Mnii)'i>ma, 
4.1^; of hydrolliorax. 4.Vi : progntnif*, 4fih ; ireaitii'ml. 4flfi ; indliip of 
potuaium, 4SA ; upiratiuu, 457 ; llliurtrativo oaw, 457 ; caiUiwit o! .iiiddeu 
awth, 4S6 ; ono ot tbo drauiuc-tabo, 4&tl ; rwwction of rib, 4RI) i diet, 



kkLUkPfls or TKB Lma. 


Twv riiivtlo*) 4lil ; cotifronltal nl^lectttsiit. 4in : morbid s.naloiny. 401 ; nvnip- 
torn. 4CS .praalratioii. 4fi2 ; lividliy, 4fi2 ; tritiprrnlure, 463 ; feeble rot»- 
pinthra, 403; Irlfiioic phydcal rigna. 402 ; ilruiTBiUdM, 402 ; virni «( r^ 
owurjr aMDctltan dvoeptirv, 468 ; dla^otd^. 40"^ ; prusuuflis, 4fl8 ; treftt- 
n«nt, 4ltS ; milStinl i^apirAtion, 4(14 -, hot Imtb, 4fi4 ; pamilur-lrriUtisn, 
404 : iltmiiUnla, 4414 -. pnct-natAl ftt>'Iivta8l&. 411^ ; caiiiuitjnn, 4(l-'i : tnnrbld 
UiBtotn;r, 406 ; »yivptunu. 467 ; llvtdltv. 4(i7 ; feeble, mpld bri>iitlimff. 
4n ; iMOpenttiK, anbtionnal. 4it7 : )'Jlll'[-l^rtlL•(] ]iulAt<-r««pl ration mtla, 
497; pliTWMl slirnh 407 : Hvmptoin* iliiria); iivouhcI yen. Wf; llliittn- 
Utc CMC, UO : dia4Mi<iHi!i. 4At> ; pniinii>''>ii>. 47l ; tniatiii«iit, 471 ; wArmtbi 
471 1 trcncUn, 471 ; ■lunulanti^ 471. 




pMbology, 473 ; mntbiil analomjr, 474 ; unyloM d»itDiMTiUkii», 47ft ; sfiDp* 
Uaat, 475 ; etrly sta^'e, 4'A : phTiiRsI licit* of eslftbltelit^ dlwaM, 4?S ; 
ijuplODO*. 47fi: mii^-li. i'ld : u'lTfmlvu spnlnio. 47T ; nutrltiau, 477: 
IraaponUuD-i 477 ; lirpr'rtroplif «f liilit veutricte of lieut, 477 -, ctmuac- 
llon of tide, 477 : fibroid phthidN. 477 -. diiRowwi 478 ; from pUuriit)' 
witli T*tr>cti<>a, 47tt ; from pblhiiUa, 47tt ; progno*iJ^ 479 i tr««tB«at, 
479 ; dlvt, 479 ; tooici. 4SU. 


BnoKcnrm 481 

OraaalloD, 481 ; morVid aiMl«akr> 488 ; B ymptom ^ 48S ; oC tmncU*! owUrrb. 
498 ; th« milil fvnu, 488 ; th« wren form, 4tS -, cvpUlvr br«n«faitui, 
488 ; tonpAraluM, 488 ; <t7iptu»ft, 4BS ; pnlM, 4B4 ; pliTltoil tigni. tti , 
rigiM of Mpli vxia, 484 : ekranto bnonhltia, 484 ; iiTnplaiiis, 49H i illadn- 
Uve ease, im ; dUgnotis, 486 '^pngnoeta, 489 : tnatintiit, 480 ; ooonUit^ 
Irritjillou, 4^0 : dlspborellct, 487 ; rtlmnUnt expnctoranu Injnrlotu at thv 
flnl. 4Si ; afier-lreMmoitt. 488 ; treatment of clironic farouclUlia, 4811. 


Kkprtrbha . 


C*ua«tioa, 4&1 ; morbid aualacaj'. 492 ; two nrictiM. 403 ; inter-lobalar and 
TMicalw, 493 ; i/mptonu. tmly ftvtitnt in tiw VMJoalu fonu. 4WI : pbY»- 
1m1 tdgiw, 408 '. Ulu«trftliv< cmm, 4tt4 -. dlagitdak, 41M ; pra^Mio, 41)41 
trattment, 4K). 



lUrilj^ in cliildbood, 4M ; Musation, 4WI i morbid aiiatamj. 407 ; t^mplous, 
4il7 ; onaet, gradual or tndd-n, -1118 : prwtratlon and rcMlMnMiM, 4tli8 i 
pnlao, 408 1 ronptralioiii, 4fM . tnmpuriiiiiry -IW ; fotid bmaUi and «9E{i«c- 
laration, 4tt8 : drapaiva, 4V>* : ha>mi>ptyti», 4W : pbvnieal dfini. 480 ; 11- 
luitrallv« caae. 490; diiwr'""!!'. 4li{^ ; Drn|{nfi(ili>, .VNI ; iratttaeni, OlW; 
antlatpUo InbalaUana, iXHJ : Mluiulaiita, <Sul : diel, rnOl. 



TarittlM. .Vn : utMatioti, liOS : oatDmunicability of tb« itiawaao, 30a -. morbid 
analniDr, -Tl34 ; unut* pbthlfiff, 505 ; io-mptnni«. 50fi ; dyspncra. nOfi ; tem- 
perature', 'liXi : plivMrnl sl^io, &0Q ; ilhistratlvt.- irwe, AiXi : mode of dralli, 
fiD? : durutluii, 'Al : i>To^nanh, 'il>7 *. I'liruiik- |iiiuumoiiIu phtliiaSa. lil '< ; 
m«d« of b>^tiii)Lu({, aw : ttaeo of sufUmiuCi TjOU : cougb, fiW ; bacmopty- 
tls. SIV ; lvuip«rMun.', ■'>](■ ; pli/Mcal -iKaK TtlU ; nlcvration of bowcla. 
Slfl; aecondarr eatarrhal pn*nin(>nia. 510 ; mod» of ili>ftUt, 511 ; «br«nift 
labetvnUr ptittit«iB,011 : wieling, .Ml ; l4>rDpi>nitur<-. -Ml : physieol aliEns. 
All : adranta^m of ramovli^ dlMaaed 1mii«, 512 -. lllutriraLlvu oaae. 012 : 
oecuional obacurlly of pbyateal ripit, fiM ; dtagnoadk. Gi:J ; of diluMd 
brMHhl) 914 : fmm cmpyma. 614 ; pmitntKiia, Rift : Irnatmt'nt, AlA : pr«- 
ranllvo tr^aimeul, .MS : tmatnvBt of xuic plithlsls, AlO ; reaction of 
t«Kipentiit«, 514 ; regular fvtding. 517 -, Uvatiucqtt of cbrouic plilbiBla, 
517 ; 4U(. 51 • ; obangtt «t air, 517 i Hilteptio InbatatloBB, ft18 ; B«aatf ▼«• 
and txpeotoranta, 518 ; necMBlty a< atft Utt to tlM dlgMttv* oiiguub B16. 



fkBtrnfouj, DTsrtnKA. 

. K19 

DciuUoa of djvpBB*, (19 ; ckhms wblah produo^ H, 619 ; obttmstioa of 
wiBd-|>ip», Alt! ; of pDlmouarir ftrteir, ftlU ; duMus <>f b«Din, SHI i ex- 
Urnal pKMurn npou lung, r>1tf •. hy nuid in p!<>arft, TtlV ; tif lli4> kttniM- 
pliBr« la ricfcsU, -'ilR : cLuwom of lung, SIV ; cauBMof pwozjamal dym- 
aaea. 5J0 : LiroiicbUI uthma, 530 . ita oaiUM, 520 : Its ijrmptonu. 321 ; 
iUphj-MCkl Rignik A21 ; (lia^iiosts. 021 : of entuf^d l>TanehialgIuiilii.I^2S ; 
of loraign bod; in tlie «ir IuUri, OiSS ; o( bronobiftl ailhais, fiS3 ; prog- 
WMb, 1124 ; tnottiMnt, &a4. 


rOBBnvi Bodies ik thk Atu-rvstw 6M 

Uorliid ftRntntnv, 5SA ; ijrinpt«in*, 527 : djipnn-*, ^37 : KjiasmodiD oonffh, 
•Ui ; p*ln In Iha cb«^ fw ; fjijwloftl tig^ns, Or^ : iiponUneoDi aipuliluD, 
&2$ ; KUigrene of luiii;. •'■S^ : illu»trtuive cue, Ci2& ; avmi vt the [«reigii 
bodj, IBID ; In Oio Uijns, R^fl : iii tint iruheK, SSI ; Iti Hi« bumcliuit, 
531 ; dlagDads, 6^1 ; Uom apaMncdla Wyiif^itlt, $39 ; frtvi mciDt>rau<;iiui 
eMnp, IMU ; prognoau, 533 ; tmAtmoot, TiU-'), 

part 7. 




Koniul il«iirolopiiii>iit of the b»Art, KVt ; urnxt nf dcTnlopmnnt, 530 ; vviffiiM 
uf malfonnulon. 030 : moibid unalnoiy, 037 ; :<;Tap(»inK, 5^ ; c.VBncwls, 
GS8 ; Bhspe of cbeaC, tSS6 ; tomponttura, 088 ; d7ipiia». KK ; adeioK 
SM; nrini!, 030 -, AlftaXira org&iifl, SD&; ttje oonnnoDOSl form ot ukI- 
foniMliaat 589 : niitrlllon, 5D& ; diMiwo of tbe patrons bone, MO ; oaa- 
roblonfi 540 ; darntioa of lif?, &1V ; mod« o< d«Mh, MU \ dU^ou*, MO ; 
l>ngnt^ US ; tMBUnent, 043. 


Ouivnr VAL^in-AU DieiuftK op thr Uj^abt M4 

OaUMilon, &M ; rhAunurlsin. 014 ; oharoi. Mi -. svphUls, 1140 ; morbid anat< 
amy, 040: valvulu l<.'<i<>iu. 045 ; idbaiion of |>ericardiain. 046; Fat- 
rni^ hapmiUwMtt*. 040; bjiierlruplir and dilatnttoii (if walU. 04(1; 

•^Bploiiu, M7: dvNpna-jL, 047: pRlpitUinn, 047: ha>inorr)ii«m. M7: 
embolUma, M7 ; of brnln. .^46 : HlnstrMlre oaao, Mf< : Bymptoms due to 
the rheninaLic diEp<«liloii, M9 : Imiiaimient of nntritlon. M0 i reUtln 

tnquvtiv; of lli« vwiouv ft'Tnu, Ul' : tvnniuatioBs, I^SO; oardiM dropej, 
ViO ; rloUiag of blood ill lite b»iLrt OOU : illilBlr*tii'« oaaua, OSO ; A\MgDO- 
tia, HM; oooMiotul dianppoaranea at niunnar, 501 ; pragnoBia, 003; 
tTMlmant, 532 ; (UgiUliv, .Vrit : aporiwU, QS3 ; diet, S53 ; diuretica, nS). 

port 8. 


Tn DnLunjBicKKDi ov Txethinq ms 

TMOibiy vet a raorbkl proeew, tSiH : ttruptiaii of th« mllk-b^uDi, 0.)ll ; attiml 
afidtTtOA?; trrrgiilivltlM, 507; nTuptiMnA nf teething, S58; tpmiwraiuni. 




OuOUSHAtO DUKRIKKA (lofuitilo CIioIm*] Md 

Causatloa, e4S : morbid uiiUomv. IMS : B;in|itoni>, 64S ; VMnlUog, M8 ; dJar- 
tlKM. OW : cliurMtirr ot »um/1», 0*3 ; rapid WMtlnf . 6*8 : exonvtva tlifnt, 
iMA ; ttimpwalure, 043 ; uxbAUktiuii, A44 : ticcufonml mnovvr*, Si4 ; dura- 
tion, iM-t ; diafCDiiciiii, ft44 ; prtwn')Bi>*> ^'•^^ • trvatmonl, <t4il ; »huiid>itt 
Uqaid. 044 : food, «44 ; koui&lM, 044 ; whlta wine nliey, US : dngt, 
846 ; bjFpodwraiia injwUon «( inorphU, 645 -, UliMtraUiw oow^ 046. 




CmubUbi), M7 ; morbid AaUomj, A4T : ■I«Ti||rhinjC of mnMHUi m«inbrMM>, R4K ; 
klNM^Mnua: In liver, B4H: ii/in|ilania, Olf) ; hruMnntw, (Wt; iDUi.-ua, 1148; 
hlond, MH ;rQllc,IM9:<!li]triictflTwrabxil«,M8:Ui«lr(>ff«uiv«ad<Mir.649: 
l«mpartiiirf, lUu ; inodfl uf dmlli, SOU ; cluonio fwm. 090 : dlapwsli. 
OSO ; progncajH, il.M ; trmUneat, 61(1 ; rtlue of upinin, Ml ; of Ipecacn- 
Milia, tini ; ot nuiiMarr, (KKl ; cpoolal tnalintiit fur infwiLs, 062 ; aetrin- 
prDl ill j<K.-t ions, Wi-1 ; clitit, 653 ; Ireatncnt «f Ui« eltronio ftMin, iWt ; diet 
do ring cauT«lMf«nc«, Gr>^. 


GAKnio-isTEBTiKAi. n.v.unniinAOs .' 664 

BpDriont 1i>pn»t«iDntK, 664 ; It* ckum*. 664 ; cantr* of lh» real bmaorrfaaoc. 
6M : mnlr^Dk nnvfiKtomm, 654 ; ita eaniu)^ IKS ; Immorrh*^ In older 
cliililri'ii, AM ; i^aiiM'n, fififl ; i:>''n"r»l, I''-'* : Iwral, IViS ; polypiw of reottin, 
tiAfi ; BTTuptomB of gaatro-lnt0Bllnsl hii>m«rrhitg», ftiiit : of melieiia ii<»od»- 
laruta.OfiU; of lismorrhags In UterclilUlliocid. IKi7: of polkas uf r#ctum, 
607 : dllgnanl^ 607 ; proeDOiia, 0118 ; irealitiHul, tiSS. 



Ulobratiok np TttK Bovstii. 


VArirlli-n nf nlcicr, MO; mnrblil aimtr>inj, AflO ; nymptotnn, iMt ;oft<'a alwcatei 
661 i 7«in ill »bdoniva, QUI ; l«iid«iiivai, 'VM ; touxlvn of pMictc*, 661 ; 
Dm stool*. Clfi ; bminarrhigv, (SS3 ; ttUt* of nutrition, 609 ; complicitlonti 
66S : llltirtratlv^ ewe. 668 ; dlifnorts, 664 : of vMnro of nl««rn.tUili, MIS ; 
|ir«|niaBls, UtVi : Ireatment, ttAS ; diet, 660 : *slii« of ran MMt, 666 ; of 
uialtud hntnd, GtUi ; milk )iia(lmf«n>le, 066: UlmuIanU, 667; iragt, 667; 
nilmbe of ailrar, 007; utiiiun, 007; Hlriogwiit lujuntiaiga, 007; pvpfJn, 


brresmiAL OmrKiKnox (iDtaBmicHpiinii) tMSH 

TirMiM of rih«trn<!ttnn, 6AN; inliifin]M«iitian, IWH: nmntfon, 668 ; BtorMd 
mtMmnj. tWH; sTmiitoms. 6T<l ; In tofaat*, 670: jwln, ITTO; rtralntn^. 
6TD : dhnhar;* of Ijloud. 670 : cotiRlJpatlon. OTO : l«ni)ieraTur«. 6T0 -. r»|. 
kpw, 071 ; In oldor children. 671 . illait«iitl«i] of Ih-Hv. 071 : vumlilnf;, 
Orl : molmn nnl alvays prusent, 071 : BiKOi) of proctntlion, 671 : m-jarm- 
tiOQ of gantm-uotu t^ffmon^ "73 : modr of dfall;, 07S ; ipecrl*! sjmploiiiA, 
OTS ; nrtfiliiii; la Uiv NbdMnm, 070 : tvntpcrklurw. 676; dorktioD, 6>!{ , 
dli^ofU, oril ; from rimrlv onllc, 674 ; frou jtMFTftonilii:, BT4; from iya- 
entny. 674 ; from lapuitnn of fa>r«l matlvr, ATR; nrognofio, 673 : tr««t- 
nmil, 67^ - {iijm-Uom of wat^r, 676 ; liMofflatlon cf air, 670 ; tazta, 670 ; 
turgkal tatt-rfrr(tii4<i>, 677. 




LFTw AKi» PKniTypni.nn» ...,,.......,.■,,..,....,,.,,,.,,..,, 8TO 

CkoMliaa, t78 : Bympt^ma. 619 : ot typhlitSa, 07B ; of pndMiUtl^ 679; ]i«i>. 
fontkm or bovnl. <(?.> i cxtniviutiuii iata paritontnni. vTt i rnxfj/nnMan 
baUud MMtom, 460 ; nmnlatiuti of hip-JoInt dlicaair, ftW : p(Bt«aKa1 nh- 
■mil. OdO; UltMratlra cms, 091 : psrforUion of riTinlform •ppvndi*. 
CS9 ; di^nosts, tKS ; «f trpbUtl*, «t» ; oX perltriililllb, Utilt ; ol pn^ora- 
Uon of Hid vvruiifvnu irrvovM, <i8S-, prognoua, OHi; trvalnuit, 8t9>4; 
^MtUuU burtf 111, HiA ; dl«t. SM. 


Ammc PsiirToiiimi. . 

hiiwiliiiii. 466 ; niorUd anaUHn.v, fiSO ; ajnoplcms, WA ; of Uia priinArj form, 
ttft; romlcinK. <WT; puia and l«u>ivruuui, 667; tcnipcntiuc, 087 . din- 
Untioa of bullf, 6^7; flnolunliou. I5ti7; loosenoH of bawvla. 6lj> ; the 
fMiondary form, (IK8; th« Uli>nt furm, BM8 ', dJAgtiMis, GtW; fr<itn th« 
tabfrcniona form, W9 ; from colk, ip(9 ; from rlioumMlam of th« aMuib- 
Itul wall. 689 ; vlBoerBl periloiilllB, 6iK) : lllustrativu ca&o. II&O ; pro(,'ii(«iB, 
a»l ; UMtmeiit. ODl ; ojiium. U«l ; IuucIk-s. (It)l : wurmtli to Uie twlljr, 
091 : diet, 091 : InfttmauL of tjnupiukltrn, (KI2. 


[.AD PSRtTOinm 

Korbid ftnfttimiT. SM ; i^mptom*. 004 ; of Ute clirnnit! form, 094 ; InsldliMiB 
b«gliiaiii8. OM ', liltiimtiv« cium>, 094 : teodt-niaBB or sbdoiiMD. 094 ; d[». 
l«nUi0a. BBS ; nneqoal nrsbtHno) of belly, 0B5 ; obMnr* QuclD&lloii, )lli>'i ; 
t«Difentare. 60K ; npld wiAling, 090 ; ocMaionkl ImproTKiiirut, OitA ; 
tkc >cut« fonn, OH ; illunlraUre omw, 4I1h5 i diuiionis, SO" ; of iho 
«lironi« font!, OBfl ; of bchU form, 0U8 ; proRiion*, OIW ; ticatiiitiat, DBS ; 
wmruA lo UUj, OtM ; opituu, BWU ; of th* di»rrhaui, 6t)» , dkt, OW. 


GMuMl«a, TOO; BrmptAma, 700; dlitentlon of ULW, TOO; lltiAtuatiaa, 7UI ; 
panoHion dalnisaB Id rUuks, TUl : oci-Mtuiml <lvipTia-ii. 701 -. othnr •rmp- 
Uia> aocordtng to umw, 701 ; iliaiiniBiit, 7IC : iiliiBtrntivn oaco, 702 : froa 
bjdnotplm^i, 703 ; prv^uasix, 7llQ ; ireiameiil, 7(H \ {arwxatwU, TM. 



rU. WOBHS . 


TMMIm, tub : danrtptlon, 706 : node of entniioe IdIo bod^. 707 -. synip- 
Mnu, gaoenl, TU8 -. special, of tUt-04d-warnia. 70V ■ of lutubrioi. 'TIHJ ; 
•odw-nal diwiliuia. 711) : thnir tulirratinn*, 710 ; of taptt-wonu. 711 : di- 
KBMit, 711 ; irratmont, 711 ; of ltire»d'«orni>, 711 : of lunitirloi, 712; 
W lapB-wonn, 712 ; rwioiu rannitugw. 713. 

Part JO. 



la lafftBt* (IrUra naoiiftturaiu), 714 : true and f>]M jaandioe. 714 : ajtttf 
taaa of ict^rw, 715 : caimn*, 710 -. fraw ouiiRHnitai lu&lforiuitioD of bits* 
dsoli, 710 , oinhonU of Ifver, 717 ; bviaorrlmsc fraiu narcl, 717 ; Ltluft- 



tratlve rase, 716 ; from arfAitltle fnBaminikttnn (rf Uie Urcr, 718 ; fram 
nmlitlicBl phtvbiU* (iriimiii nuliRnnn), 718 ; jmnndlu in eblldhood. TlS , 
«Ba»s, 719 ; dift9&<»»u, 7ltt ; pro};ii««i)'. 720 ; tre*tm«at, 730. 


CoRomrmx or rmc LtTRii. 


Ckiuatian, 722 : morbid anaiomj-, 'iH : ijinptmnm TSJ^ ; miiw of mtiglit in 
Mc, 7^ ; dy>jMptio iqrmjitoiiUs TiA ; lightixrlourod irtool*. 733 ; dia^mla, 
73s -. ItltuUfttiTo cMf, 724 -, progaoiiv, 724 -. trvaUitoiil, 724 ; dlM, <S4. 


CntBBOfiis OP TUB Livcr. 

IKBUHIB ifF T1IE LiIVEli.. .••.•■•■•.......■... ................. 

Caasktion, 72B : iiwwWd unBlnmr, 73fl ; two varleti**, 72fl ; iif mptmu*, 787 ; 
ot niiojihlc clrrliMiH. 727 ; Indlgintloii, 727 : uottM, 7S8 : »»thy Mnt ot 
skin. Tin ; liKiuorrbwra, 7^ ; of )irpertiO|ililo cirrliosta, 72H ^Jiutndlce^ 
72A ; ealvginnfaiil oFlfror, 726 ; diagnoois, 720 ; pngnai t , TSB ; trwl- 
nwnt, 780 ; afcricntth 7!K> ; piinu«iit^isi TV). 




Caittktton, 791 ; morbid wiatAmv, 7:li ; nymptoinii, 7^1 ; o&largmiaKi of liv«r, 
7<tl ; ibMneo ot |Nilu nr t^iid«ru«iiis, 7d2 ; digMliv* dMnrbuivo, 73S ; 
tmnnilft, 78S : cpdema. 732; k]dn«fi uid Bpkwn ofMn inpllcmbid, TS3: 
dlagncwl*. n'i : prognvaU, 793 ; oocwlonkl eonpleU reoOT«nr, 743 ; treat- 
m«iit. 7^18 : iodiuu, 7»8 ; irou, 7S9 : )ib«nd dtol. 734 ; lea air, 731 


pArnr Lrvsa.. 


CnnutJftn, 73tt -, two forma, 735 ; morbid Anatomj, 7S5 ; BjmplaDii of fatty 
iultllraltou, Ti!i\ e-aUra^metil, 735: oeouioiial Uiiiilcmem, "TM ; diag- 
nwia. 7.)0 ; prognuciK. TM ; truBliiiviiL, 7^1. 

qpAPTBB Yt. 

nrnATiD nr tub Livbr . 


OauMtJon, 7!t7 : morbid anatomr, 737 ; dMoriptl«n ^tliir lii>nift eohinoeoMn*, 
737 ; «vrof.foin«, TIW ; nwrl'liiit: in livi-r. iSSI i rnrolv j&nudlre or ueitM, 
TSD : illiKilniliv* rw, 7MI ; ti^mitiiUiflii if Ii'tt ulonu. 740 : diagnoiiui, 740 : 
prognMb, 741 -. traatmenl, 741 -. paraoeiitwlx, 74S ; ILluxtralire mm, 743 ; 
UMtment bj cleotrolrst^ 742. 

IPart 1). 


Tub Vkucb. 


CbarMt«i« of 111* nKn« ia lu>>l(h, 744 : vwUtJoiiR iii tt» (juaiilitr. 744 ; tlivir 
auis«f, 74A; *arUUoD« in the <|uiiiitltT of solid mftltoni, 74.%: of iir«a, 
74a : einMi ot Iil)iKt'<«. 7I'> ; >1biimitiiirii, 744 : it* mmm, 74lt ; bnna- 
tmia, 746 -. tta uauKM. 74H ; frvin iniuiion of tim paasi^B bj (h» bilhar- 
tin hnvatribla. 747 -. r«t*niion ot uiinc. IW ; ii» natui*. 748 : aooturaal 
iDcoDtlaencn ot urim, 74<j ; ita oataic, 74fi : and irMtment, 70(1. 





BtttGin^JMaiB... mt 

JOD, TlSlS ; nwUd iBalnnr. Ti& : tlia snnnlu- kldnoy, 7n3 ; tti« taXty 
Uda»r, 7AS ; th« uajrloicl kidnev, TM ; nrmptonks, 754 ; lllnitrmtlve 
«tM. 7M ; lutKmia, hiMwUcttv Bud votnitin)!, 7M i acate eiMtfrbatiooa, 
?IUt-, IIIaaliMiTa cow, 7S$ i iimidiouB promw of tb« Knuiular kid- 
u»j. T5R ; llliiRtriitivx rroM, TME ; t)i.- «inyluid kidnef, <&b ; r«n«l inadc- 
qoMj, 7n8 ; 9oin<-tiuit4 itftta in ^oaog fnf&iite. 'r>M ; dia^noaia of mdaI 
iiMim, 7S9 : progauBU, TUU : irMdmenl, THu : diM. 780 ; apurlnnU, 781 ; 
SspecJallj valuiblif <u urii-Tui». 7LI1 : diaplionttio*, 7tt1 : Iron, 701 ; tn4t- 
BCUl of chrotik altiiimiiiuriu. 7(13. 


LEV or THR KmncT , TM 

la Um urioe ooinmau lu children. T)KI ; fumiMloii of uric lu-ld in uriuv, 
TiJt ; formttioB vf uxidkti; u( liiao. itf-l : cauMtiuu of catoutiw of kidnujr, 
TU i ajBiploiiuh 704 ; liieniitturiK, "O'l ; paiii ia loiiia, TVC ; itliisUAtiyo 
«iiM, 785 ; naai colio, 7U6 ; iropMtion of tUtnn in DratoFf 7SS; utoDw in 
blsddvr, 766 ; diignoiit of calcului of kldn*j, 767; illnatrativaeiM, 787; 
pKgiMMii, 708 : UMtmmit, 74W ; dlut. TltH ; ftlhnlla, 708. 

CilAPrsa IV. 
TnHoCRfl o» TKK KiDimr 770 

Strvam* of Iciilae/. 771) : laorbid ftnaUimv. 770 : nynititomit. 770 ; KirvUini 
abdvmca. xM; Mgnt of |irattar«, 771 ; illaiilrativH <'Juh>, 771 : durw 

i« of 

773; hrdrannphrmitK 7^: ouiutloo. 773: Bynptoma. 772; pftlntoM 
tomoor, 77? -, ductuatlva, 77S ; dlagoMlK of noii ttunoors, 7T3 ; trwUnent 
tt Lydron«phTO«ii| 774. 




T^o frniDc, 77"> : cniiRjliun, 771 ; eymtiUnnit 775 ; of catnrrlikl valTitU, 77.> ; 
«f AnhthotM Tulrit:*, 77(t -, dla^oiin, 778 ; trMdniAnt, 7Ttt : of ckUrrhal 
Tiil»ili«, 770 ; oe apblhwi* rolrili*, 777. 

IJarl 12. 


ov rmtt Skin. 

iK«lB> VW XIIK I»l(1,,,„,, .,.,.., .•.■•••••••■•■•.•-- 

The liftpaUr erupUons. 778 ; Jirariiro. 7T» : »lrophuln«, 779 ; vmIcuIv erup- 
Uaua. 7?!> ; hurpea, 77l> ; imniphisun. 770; ditrslion of ihn spata. T»l) ; 
tnatMcat, TVO ; puxlalar L-nipiUnK, 73(1 ; «cth;iii», 'Kfi ; koaIj' prapLicn>^ 
7M ; pMfiuU. Tijl) ; raluo of pDrchioridv of merourj, 791 ; alvpocia 
ATMtU, 7ttl i tr«iitni«m, Tljl. 





thMM cifnpl^c, "XS ; il* Tarlolion, 789 ^ •rrth<im& ' <>X*3c, 782 ; •mtumta 
MpKlttam, 7«a ; ■rytlinm> intPrtrigo, 7*!* ; the belladMiiia r»h. TBS; 
dugnodi «( Kiniple srytliontK, T^lt : troaiinonl, 78^ : erytbriiu nodonini, 
9n ; (jrmplniBi. 7^-1 ; tlluRlrftllr« fue, 7m ; diwuosts, 7^1 '. treatment, 
W4 ; nrtlevla, Tffi ; lymyioms, 71M ; dlagiioals. Wi : trMlvteHt, 7M ; of 
llw e&nMik form, 76A ; row;»lB, 78Q ; Bjrniptunu, 787 ; iltuBliativo case, 
WT ; dhgneais, 7V7 ; trcatmont, 388. 



VmMtA 78ft 

OMUmtion, 780 ; ■jrmptomB, 790 ; Tftrietiei, 790 ; Msmn» dmplex, 790 ; Doiemft 
rabrum, 790 ; tM»«mji oapitia, 790 ; impetigo contagiosa, 791 ; eoMma lani, 
791 ; eoMma infantils, 7U1 ; illtutxative oaae, 791 ; diagnoBis, 792 ; trcat- 
ment, 792 ; diet, 799 ; loakl appUoKtionB, 798 ; treatment of the rarietiea, 
794 ; batha, 796. 



Morbid anatomy, 796 ; iTmptoms, 796 ; diagnoeia, 797 ; treatment, 797. 

chapteb v. 

The Parabitic Dibkaueb 798 

Bcabies, 798 ; the acaroa soabiei, 798 ; the farrow, 798 ; nmptomB, 798 ; in- 
tense itobiug, 798 ; TariooB reahes, 799 ; dlagnosie, 799 ; treatment, 799 ; 
tinea tonsurans, 799 ; pathology, 799 ; symptoms, 600 ; on the soalp, 800 ; 
on the body (.tinea oiroinata), 8O0 ; diagnosifi, 801; treatment, 801 ; In the 
infant, 802 ; in older children, 802 ; various applications, 808 ; tinea 
favosa, 801 ; symptoms, 804 ; diagnosis, 805 ; treatment, 80C. 



Two diseases often confounded blether, 806 ; tme sclerema, 806 ; morbid 
anatomy, 806 ; sclerema adiposa, 807 ; symptoma, 807 ; rigidity of skin, 
807 -, low temperature, 807 ; rapid coarse, 807 ; cedema of new-bom In- 
fants, 806 ; symptoms, 806 ; diagnosis between the two diseases, 808 ; 
treatment, 809. 


diflioultien connpct^d nifh tho invcMif^tion of diaoasc M it ooonra in 
rly Uiv luny be t-iwiiy v\(^,'^i>r»t(-4l. Tli(« Mibject i» no douLt n Hpcciol 
le : bill wbpii tbe lirM !ttniiigt;ii«»)i buK bttL'ii ovei\-ome of dealiufr witli 
krientjt who caimot deticribe tlieir seu»ationa uiul who tdiow their diiiitreKii 
crit'S aii<i gestures which it requires experience to ba ivble to interpret, 
j(- (Jiif f obstacle t*i progi-nM has Ijeeu aiiniiouutetl. All iiec«»«irj- irifnr- 
>D OB to the oniwt nod vttrly symptoms of the oomplniut cau ubuhUv bo 
' from the mother. Most women m© pfood obscirers. Aftec'tion 
anil ai)xiet>- inrreAHa tlicir wat^ilifidneiH, and ninhe them fairly ncctirate r^ 
oonlent nf every outward clumge. The Ktitwa hud by them ujtnn particii* 
fair ph4>noniAna is not, indeed, (dwnvft a tnic menRuro of t.ho rt-j\.\ inipor- 
jtenne of tbs MvmptoiOH ; but it is voHy to correct luiy uudue emphu«» in 
narrative or our own jiid^ineut and esiierieiirf. Still, we laiiBt guard 
I from oeina miHled by the very fulness of the rf port. : facta niaj' be 
with coufidoQco, but volu&tcci-vd oxpluuutiou of these facta moat 
DO account ht oUowi-d to iuiluouco our coucIubIouh. 
Wben called to a (dck child our first care should tie to give un attGutive 
lienriu;! to the etatemeut of the mother, BupplTin^ any gapa in the hiutorT' 
br Huilable qnetttion^i. Having tlius been enltghtened as to the prertoaa 
ImmUIi of the diEil and the nature of the enrli«iiit symptoms, we h»ve next 
to eollvot what information we aui from thti Hp[ieann<w and mAnner of tba 
[Atieut To do thta w-ith euccoes we miist possees ate«ady a certain famil- 
inrity with the ways of iiiffmts and young childrpn ; but Ibia in easily bo- 
■{iin-il with a little piTieliop. Again, we haro so to regulate our own hear' 
iuu 1^ not to alarm th« child, who is alroudy pcrhajxi in n Rtato of disquiet. 
B ow beeu t«id thnl a nutural fondiwMi for children in iiidiiipcntidbic to 
■WMMM in tbifi bi-anch of medicine ; but this in an exaggeration. A quiet, 
gtaia] manner with a pleasant smile and a gentle voire will Konn disBipaba 
Ah l^>p^cbeu.■iion8 of the piitieuL and paa lua oonfideuue. Lastly, we pro- 
owd lu It physical cuiniiuuliun of Ui<* v-nrioua orgiturc This, if done de- 
lihefait>ly aud without abru}iUieBH or hurry, can be efflectvd In losst caws 
*itbout niDch trouble. 

Th« nwin diffirulty in the diagnoRiR of diamae in early life ariaeH, nob 
Itrmi the abmnca of intelligent m{)eech on the part of the patient, nor jfrani 
mi uncertnin^ in tho Mooj^nition of viKiblc irignn of mifTcrint(, It Riiriiigs 
b«n tbo Jierplesitywe often feel in refeniug these syuiptoma to their truu 
fwigin. Chihlreu are not merely little men and women in whoxo bodies 




difM:4WC manifoRts itself by osArtlr the nuao tokens tlmt are ftunilinr to 
iu tUu vr.nL-: of till- oilult. 'Ihvy liitve H^x^'ial o mnt ituti<.iii(Ll pi-niliariU 
vliich give to djii«aMe iu eurly litv n vliKmcUr it doetf tiol afterwards ivtmn, 
and inTBHt Uie coniiuou<>st funiia of lUu^kh wttli. Htmuj^ feiitureti whic 
luaj- be » source of obscurity and confufiion. Tlie looet utrikiit^ p«ct) 
aiiiy of cJiildliood is a mtu-ked excitahility of the nervouH system — ui 
sens of HBUHiliveucsH wUicb aiij doviiUion (miu the lu^iUliy titnte brings at 
ODce into proQUDeoce. Conseqncntly, ii functioiiA] dfirati^ment wlticb in 
tlie adult would givn rise merely to idt}jbt lornl tiyniptnniH, in tbe child 
uuijr be fti^xwuiwitiKl by migiis of iwT«r« genenl diHtre»i ; aiwl the indica> 
tions of local BuBVrinj; may tj« thus oi-pidwlowwl or t'omplctcly conxxnled. 
A ooiiimoQ exftiaple of this ucrrooa excitability is &ccu in the disturbance 
which often resnllA from sn~allnwingi)omRiiidi(;r-stib1e article nf food. The 
skin bocomes tntmilij; hot, Uin oliild is in a aXaUi of e-xlrfine ngitntion, i» 
norhupH con'mlMd, or lies in a ntutc of stupor fruui A^hicb he am with dif- 
ncoltjr be roused. In mich a case tlio istiLtc of tho stomnch in fipt to be 
orprlooked ; for c-vt-n if tlie ehild Tomit, which dot* not alwavB happen, 
tlie Ryniptom may pass nlmoiit unnoticed as one of the fonsequenpea of 
the <;i.-ucral nvn-otis perturbation. Oiicrai H\tii)itori)8 of a lik« chanu-t(?r 
Duty ficcoutpiLity Lhi' otUKtt of any acute ilhtewt. and thmir MTcrity beont do 
relation to the importance of the ailment of whioh they are a (.-oueequeace. 
JkB pcofouud a disturbance may be excited by the simplcet functional de- 
langement as by Iba severest or<::[niiic malady ; tio that to the eye ac- 
ctntomed to the orderly procrmK of disonse in the adult KymptoniK »«ectn to 
hare lost thoir value and to t>& calculated rather to mislead than toiufcmu. 
This excitability of tlie nervous system in early hfe is a ]>eruliarily trhich 
must be taken into iuvount in erery case of amita illnew ; tod we must 
endeavour to sej^nitr the locnl Kymjitotns — those vhicb point to mixchtef 
of a special orgiui~fn>iii otbun Truch are merely ike cxjiffoSHiou of the 
l*ODend distremL Such local xymptmns are the coancb, rapid bn-atbing, 
nitd ai'tivo iinreti which point to acutr- lung iliBttme, tlie Bijuiuting and im- 
mobility of pupils wliicfi are 80 characteristic of cerebral affectiona, and 
the peeulittr jfi-kiiig mn^-euteut <if the Icpt vhich, cond^iDt-d with boidnesft 
of the abdominal uiUHcleH, betray tlie existence of colicky jxun. 

Local symptoms are not, however, to be di8co%-ered in even,* caae, and 
oren if present cannot always be reUed u{^)on to fiumiali tr«»tworUiy indi- 
cations. Omng to the exaggemt«i1 imprewilbility of the iwrvous syBtem 
B poculiar Kjinpathy o«»il8 between the %'nrioua orf^na. Coneequentljr, 
e^-mptoms iuduccd by initatiun in any part of tlic body are fteldom limited 
to the pail; actually atTtctfd. Signa of distress nriac at the same time 
from otlior and distant oif^niiN ; indeed, the orj^aii from which the more defi- 
nite syinptoms appofir to arise ia often not tbo organ which i» the actual 
»Mit of diauasu. These deccptiTo maiufeatations are moat frequently no- 
ticed in the case of the BtomacJi and the bmiii. Intlje case of the Btnmnch 
the rewijouae excited in thiaorfran by iiiitation in dhttaiit pnitsof the Ixjdy 
penistji wore or Icm throu;;h hfe. The voiuiUnf; of prcf^naucy and dis- 
onlered uterine fuuctiuu in tlie female, imd of cerebral and renal diaease 
iu both mses, is n matter of common observation. In the child, however, 
this sympathy ia still more frequently maoifeflted. Vomiting is n commoo 
sncntom at the beginniu}* of mo<«t forms of acute illncsB nod in many 
dbfloren may be excited by any casual disturbance. The biuin afiutu 
tihowa a iDnvkcd sympAtby with irritation of the more important OTgana. 
UeudacTie, i,-erli;p. delirium, and stiiiwr are phenomena by no meana oon- 
'^ned to caseij of intra-cranud suftei'iii{^. Any seiioos indammatoiy dtMasd 

the child maj be Bcoompiiuted bv bikJi nvtuptumu i i»iU-«d, the ex- 
, pnsricHi of c«r«bral 8^-mpathv maj be so <lmiled aa coDi{i)etely to divert 
atl4!Ution bom the {tiiJi «lii(r{i is reall; aflected. The onset of ptieumonia 
w aoiaettmee ooiapliciiUrd by sacb decepUye STmptomit, and Uic a&me oautto 
fnr iDUtapprubennoD niAV be rouud in caaea of iKriciu^lilia luitl inltiimmiition 
of the pvritououin. So. nlst^ the vtol«iit uootunial tletirium — tlii< 80Kume<l 
" night tftront "—of ehil<IreD wlio suffiM* from worms or other form of gOB- 
t)\>-iDt4--stin.'i] (lenui^emrtit uuiit Ik» within Uie experience of lUl. 

Out* n| ll)«> l<«^t iUu»<tnitious of tb(f excitability of Hie iiervotw sviiUtui 
in early chtJilhootl i»8fi<^n in the easi' of eonvul»innR. An evlfinijitic miui^ 
ia A symptom «4iicb, in the uujority vt cusvn, luis u bur tew ^ravo u;;aiti 
caoce in tlir youDij child tluui it butt in tlie adult. In the hitler it is luwally 
tiw PTidence of mme •lerioufi oerefaral leuon, snd its octnirrence rxcitiM tli'o 
ggnaXcst alanu. lu the- ciiild, ou the r<.tutiiir>', "a fit " is a cominon ex- 
pr c witili of di»liir1junct- iii tlie lU'^rrmiB HyHtutu. It may In; inducci) in nuam 
cluLilivii by » lrilUu(? irritant ; and in cases of acute iUnesti in ufl«u aevn at 
tit bcj^^tiiug of the attacit, taking tlie place of th« rigor wltich is so 
fsiuiUiu- a ttyiuplom at l^ ooaet of the ftbrile disease iu the adult Cvii- 
rolriiuiift. however, are not always, in tiia child, uf this inuoreut rliarocter. 
In (<arlit>r u» iu tater lifo, Ihoy iiiny occiu- as a (.-ousequODoe of <:«r(;bnil diB- 
' «Mc ; but iu such a ca«e they ore repeated frequently, and are uacceeded 
In cotna, rigidity, paralyflia, and other ^^pin of centric trritAtion. As a 
irulft. aingle tittt, or ooiivultuoiu) uxiBCct>niiuuiic<l liy other indication of 
I iiitm»-l6»on, oociirriaj; in no appnnDtly lictUlby child, Hr^ purely rctlo-x, 
and have no gnivitv whatever. 

Extretuc exeitabiliiy of the uerrouH ini-Htem in, tlierefore, in early child- 
hood, s natumi pby^iolugicid oonditiou which exi^rcinea an important influ- 
me* in di9turL<iiig the unlerly evolution of »vm)>tomtt. Into an otliorivitiC' 
nmple ouac it introduct-4 ii number of n>hiudiLul feulurcs which coiifusc 
tlio ob(ierTi*r. and muy iKwiiibly divert his iktlention froiu thu actuid seat uf 
suffering. This normal nervous irritabibly is subject to yariatioua Thus, 
it mny be temporarily inteuaitied by caitwct which pi-oduc« sudden depre»- 
non of fitr«agtb, mich as severe acute di.'ui-1i«Ma, or rapid !os8 of l>lood. Iu 
riekel«. again, n poculiar feature uf lh« diiieose it; th<> exlraordiiifu-y «xcita- 
bilily of uw nenrous eyatem. As a rule, howf^ver. iu chronic dieeaBe, when 
thi! int«rferetice with nutrition in slow nnd long-continued, on exactly op- 
iitc t'tfe<:t iii pi-oiliice<i. A yitung child, I'Hpw-iAlly an infant, if ex[>om>d 
conaidcmblc Umo to injurioui^ iulln«noc»t so &• to suffer both in 6f«h 
strr-ngtb, gradually loses his susceptibility to reHex irritation, and the 
excitabdity of hia nervous s_\-stein becomeii less nnd less obvious until it 
finally liiwippeara lUmost enfirtly. In n i-hild ro onffioblcd, the sjntom, 
instead of rva<^tiug violeully agiiiiiiit auy iuteruurreut initatioii, npjKant 
almoitt tnaensibli; Lo iitmiii!t impreiwiunK. If an attack of acut« illnesa 
iK-cur, we lnok in vaiu for the usual ingiw of genenU difMpiiet. Evgu the 
oQltiiary ^-uplomH of local suflering may be diuiinialiod or supprewed ; 
were it not for tlie inci-ease of weaknt^^ and perhaps for a rise of tern* 

p, the onmplicatton might lM>altog(<tlwrovi)Hooked. 
Thia obtUM'iifiM of the nervous fiT8t«>m ia only seen tm a eotiMciuence of 
itiimed and profound mnliiuti-i tion. Iu all auch CAaea, tliervfore, 
null! wati^h very narrowly for intlaniuuitoiy couiplicatioim, reuiember- 
' timt HUrh intercurrent tliiieas«s may gtvo rise to but few Byiuptoma, nnd 
ugr csuoly cucape notice. 

AnoUii-r peculiarity of early life whirli ntiracta attention, is the large 
Am tolten in iufimtile disordei-a by mere disturbiuice of fUDction, nnd tlie 




iterioua con8equ(>nr(>8 wltichtDAjmiae from *lf!r»iigp)iiciil a* iliHliii^rtiiiJiiMl 
from dieeow. InfontH quickly piut vrith thrir bent And are easily oliillcd. 
Ifaojr an, therefore, peculiiuiy prono to c-ntairluil disonlera and these, il 
aevon, mav produnn nmtcrial inttrference with the fiim-tioiiH of the nrgan 
nfTecti^d. No doiilit t)ic oxcitAhility of the nerrous iniriileiR he1[xi to incTpoAc 
tbo (H^vitr of thcso di-nuiKcmeiits. The cotnmotioD into which the whole 
sjnslem in thrown by th« iittack, tcmdH to oxhftust th* patient nnd crtnily U* 
onbancfi the enfe«hUng inducnve of tho comphiint. In infau<n', deuth is 
a not uncommon cooHequeitw of thene disorders ; nnd it i» for this reo~ 
80D tlial, prift mwltin t-xritmiiAtioiiH iu Lhit infant nn ho often tiiitottisfntrlur^'. 
It conatuutlr linpjteuH thai » young child tit M'tzud nith alnrmiu^ tnuiptonu) 
of UlDflBS and quiL-kly dies, yet on opening the boilr no sufficient morbid 
^jpearasoeti ai'« dibct^vered to explain the fatal lasue of the case. 

Chil<lren differ from adults in \ei another rpspeci. DiiitheUc tenden- 
cies (ire eBpeeially ftt-tivci in tarly lifo. Tliey o\ort n reiimrUnblo tnfliioncQ 
upon the growing body, ehapiug the figure, moulding th« fc^turw, and bo 
onlehng ii\n Htnictiire of or^uis Uiat any interference with the nutritire 
proc^»iw0, surh IU may be pmdiiced by ordinary innanilary agent-iea. is 
followed l>y widely di«tri))ul4!d misrhiej. 8ir WUIinJu Jonncr hiut di-nvti 
attention to Uic uuiubur of ort^os nfTectcd at the some timo in cohm of 
diathetic iliacruiC iu the child. In u bad fasc of inlierilcd syfdiiliM. few tia- 
gues or organs ent-ape ; in i*(Tofula tlie lenionM may be almost unirurKal ; 
and iu «c'»te tubercuWsu'' all th* cavities of the body mny be Himultane- 
miuly aUt'Ctei). TI1118, nocurdiug to tho coustiliitional rhurncter of Llie pa- 
tioiit luid tli« nature of liiii ailment. » child may die from meiti UTMit of 
fuiictiou, with ti)«ii('H Houtid. organu lieftltliy, and no morbid appramnces 
left to declai'e the nidiire of the coiiiplaiitt ; or may succumb to a profoiiiid 
and gcneni.1 ili!»i>jiaf which vi»it8 every £«ut of tlie IxmIj and Icavott »L-;ii-cfeIy 
any organ unitlTti^ttul. 

It i* eomctimcs mud that in a healthy child nculo di««a8« natunilly tende 
to recover)', hat thia statement must not be taken without qnalitimtinn. 
There are aomn diseaneH, Kuch as typhoid ferer, measles, and perhapa 
erouixtun pnr-umonia, which commonly run a mildor course in cnrher tlitin 
they do iu later lifu ; but there arc otlienv c»|}cciiitly acute affections of 
tho ^iuttro-iiite)itin»l tract, which weigh witli peculiar severilj upon the 
young. In infancy the piilient is ku dependent ii]>on a frequent supply of 
nourishment that on abnipl iutei-fcrcuce with the nutritive ptxHcsses, sui-Ii 
aa or-ciLTs in aome forma of bowel comphkint. in an event of the iitniiwt 
pr»«ty. Oft/'n it is followed liy so mueli exhnustioD thai the infant rajv 
idly ttinlcK nnd dieti. It is this midden nnd rompleto cutting off of tli« nu- 
trittvD »upj>ly which conetitutes tlie chief danger of orute diftcaec in the 
child ; and iu eiuly life iJhiess is often Berinua in exact proportion to 
tlie degi-ec! in which the alimentary canal talcM part in the derangement. 
\Vh«n dif^vstiou in uot nrrc«ted and tho systom Htill contiuu<>s to mocivo 
uoiu'isinneul, the; child, if iu favuiiniblo conditions and of healthy constitu- 
tion, will prubnbly recover. The recuperative power of nature is very 
groat, especiiilly in the young ; but that it may b* freo to operate it is es- 
seotinl that no tiufaTourable condition l>e pretient to impede Uio natural 
course of the illnr-Hs. <h'er and aboro grave implication of the digestive 
organs, nthoi^ititowArd elements may enter into a case, and each of Uif^se 
had an iutlucnco in weakening the natui-al tendency to nien<). llie age is 
a maltt-r of grcnt importance. A new-bum infant ha^ but a feehte liohl 
tnmn Hfi* and quickly succumbs to rui attack of a^ute iUnoffi. Tiater, tlio 
ODild may bo burdened with a diathetic taint which hiu fllmdy iraiwir^d 




hix nutrition aiid loirered Iiir vital eser^es. Ifoi'eorftr, be m»j lie bam* 
pere<t by uiih<HilLhy tMUToiuuliiigs nliich iiiUiiistfy tliti woftkoniof^ Intlueaoe 
of the orii^tiiil ili»cui»c, and, iudecd, by tticuu»vlvc» uro ofteu powerful 
enough to prettnt rceoi'oiy. 

Tlicr<>fnre it is only iu diildren of beiUtliy conatitution who aro plscfld 

lu favourable conditioiiB that LlLnees oitn be aiid naturally to tend to re- 
r, and io them uiily ufter tbv period of eorliitit uifiuicy has |uu<aed by. 
And in oaaei* wb«ri^, uutnliun not Iwiii^ t-uuiplet«ly niTPRl<!(l, n liiiiiUKl KUp- 
ply of nouriiOiincnt oMiitiiUB) to b« intruduced iutn the svM^iii. 

Suddcu dmth in early uhil<lltood. i» dim, us u rule, to lurynKumun, to 
ayncope, or to coUujHie of lb« lung : lutd ocouiiiuually it in seen im a codkb- 
qocDoc of eoiivulHioiia Spaam of the luiyus is the common cnuso of deatli 
iu rhildreu who ar« apparently liealtiiy. TIiom' who lUu euddenly iu the 
ouume of an »<;utv tllueiM or during cniivnle»ci*uce. do m uaiudly from ayo- 
ooptj, or iu mrt-r faee« from tliroiubouii^ iu the puluiouui^' arltiry. In 
wtiaCed infante sudden death is moi'« commonly the couii^(|Ucnc« of pul- 
tttuoary coUajiae. Wlien a, disease is al>ont to end fatnlly Uie exlreuiity of 
Uie dunij^r ia abown by a marked alteration iu the tfiiiiMraliire. Iu Homs 
casea we notice a rapid fidl, tho thomiomvt«r roKimoriiiR only 9(» " or 97" 
iu the re<;tuin. In otbent Uicrv im a ii(uldi.'U iuixvuHu in the iKxlily heat, 
and the teinperatuit.- ritM.-?i quickly- tv lUH^ or 109'. The nnlc-iuortam 
eooliuff JK iiRiuilly noticed in chronic uilinetita and in bmiirhitis vrillt oot- 
lapse of UiL* luu^. The rapid in<:r<-ai>« in iic-nt i» commuu iu cbivbiol uilvo- 
tioua and in cubck of iicut«; jia-tti-o-iutf-stiual dcriuitfctuiuUi. Otlictr im- 
bvoorablo aigns an? hvidity uf facL>, ri^fiiiiid tjf food, thruHb, rapidity and 
fe«bl«ne)is of the pulae, b^aviueaa aud stu]H)r. 

Iu ucuU- diiK-itno when recovery tAken \Atu:e, convaleat'ouce i» usually 
rapid. Iu au uucuiuphi'utod csmv tlie 8t.rvugLh iippeiirs tu be n-coverwd al- 
rnniH as quickly a^ it wax lost. Dircvlly the tfnupLmiture falla, digestion 
ami nutrition resume their cour)><.' aud iu a »tu-prisin;;ly short time the 
child i» welt. If couvaleHi'ence ia delayed in ancli a com- it 18 nlnioitt ini'a- 
riably tJje conaeiiuenoe of a complioatiou, and it iiiuKt be i-cnietiilM-rpd that 
ihJM Bcddeut ii for from uncommon in the child. In nil forui» of oAtarrhal 
derangement — n vai-iety of disi-iiaf) to wlii(^h cliiUlhood, ua has been said, ia 
paealiarty prone— a gaatm-iuteMtiual eomplii-atioii niny incretise tbo gravit)' 
of tliA illrK!»* ami delnv the jmx'ei^ of n')mit*. Nonietimoa the dcpumtire 
futiRtiomi of the kiduuyn ari'^ iiupvi-fcutlj pvrfonui-d. Somotimea nn unab- 
tortKtd patx^h of coti^ilidntiou in iho luuj* iutcrfcrc-a with the return of 
rtifn-rlli In III! raaes, therefore, where convaloHt'euce from at-ute dUeuse 
it i haviug bi'i^iui. appears to falter, ve shoid^i nuike careful e\- 

Uiii I <; 'dm various urt(iui(t ito as to discover the miscluL-f and apply a 


In eaaes of chronic illness convalescence is usually ttirdy. The delay. 
on <Ioiibt, ia iwrtly owin^ to the fart that thin clasa of diseaae is common 
in ohildrMi of a arrofulouM Imbit of boily ; aiiil the stritmoua cachexia ia in 
itMlf a bar to nt|)id iuiprovDment II is. however, also often due to the 
nature ol the illuoDs. In early Ufe, especially in infancy, cliroutc uilmouts 
aimu]i>uly aAect tlie alimentary caual, eilher primai'ily or seconilurily, and 
the pntj^rewt of RUcb comphuota to nMwvitr}' iH inTarinlily xlow. 

Iu the folliwiu^ W(^ tho t«nu " infancy " is coutiucd to tlie two Biitt 
;ear» of life, or to the iiciiod which eiidn with tho t-uiupletiou of the lirut 
ilanlition : ■"early chiUlhood " to (he period between llie close of tlie aec-- 
imd and the dose of tbf^ fourth year. Tiie- period of childhood ends at 
puberty. TUia impurtuut chuujf u uccura at riuious ugea, espcQiaUy iu girls ; 

DisKARE nr rmLDUKS. 

and Komc jount; pi-opk' remaiu cliUdreu both in mind and \*oi\y to a mneb 
later <Iat« tbttii utJiertt. 

In the ejftitninat\f/n ol au iufiuit ur yi>uiig child eyoy core should bo 
tukfiii to infiid HbrupUiewt or Uurrj", We must reniBnibcr that w« haw to 
do witii Im^ui^k wIiu ol-I uot ftoni rPiiMon, but from infitiiict; tbat taty sud- 
den moveuifiit frigbt«iis theiu. ii littl<< pre«Kuro liorts them, and io cdUuir 
catie a cr^ uti<l <ii^tru},'^]i' briiit; tin- L-\niiiiuAt»iii ubruiitly tu a close. Again, 
joucj; obildrau, lut u rule. disUlM> tlii" nielli of a Btraui'e face, and if old 
tiuough to uudeiBtand tUe object of tlic visit, are already prepared to look 
with distruat upon tlte "dot-tor." Still, it \n u minUkV to 8ii[)i>otM; tliab 
children alirays mak« uniuaoageiiblv jntJoulM. They are uo doubt ([uick 
to toko fright ; but it sbouUI be tbe voiiHUmt caro uf Ibe [>rautit)[>n«r to 
avoid any look or gesture which may arouse their suapieiona. U he look, 
ii]Mak, au<I moTe gently, ajid <ln not linn^', most young cliildren will let 
tlii>uiK«lvc« 1)0 rxaiiiitiod tboroiigbly nitliout jrrr>at difflcidty. 

On Antcrin;* the room it in woU to aocatrtom them to our pro90Uce be- 
fore w even apjiear to iiotiRO tliem at alL. Tliis inten-nl coo bo usefully 
on-iipiml by qtieHtinniiig the mother na to the onset of the iUuesa. and the 
character of Uk- early HvniptoiDB. \V*e oan olwi take line op)>nrtunity of 
inspectiug the luutiouH ur vomilttl matters. Li ftearfbi»({ into llio liiatory 
of the cuao it is especially deiurable to ubLiiiii wiik- Klartiii^'-[Miiiit for our 
investjgatuHia The (juetitiuu '" When did tbe iuitis]>ositiiju l*egiu V " often 
receireit only a va;;ae reply ; vrbile an inquiry as to tlie time which haa 
elapsed mnce th« ciiikl was last in good bvidth iimv elicit an account of 
more or lesa interferencv with imtrilion and iiidettuil«' malniae esloiidiug 
over a (!i>ii>u4lenibh' inlerral. Homo liict ifl ofli'n reqidretl lu obtaining a 
deiinite acmunt of the brgiiiniii;; uud early pro^^'reiiH of the illueBS. It is 
important to avoid miggeMtiiig a rt-yiW by the cliatiu-ter of the queatioOt 
while it ix often nee^'marv to Ite minuto in our inquirieti in oi^lex to stimu- 
late a fla(;giii{; memory. 

In infnntM luid young cbiltlrtui much may bo learned from mere inapec- 
lion of the face. It is au advanULge in these ciuies to find tlie patient 
aaleep. U'e can then atudy at leimune the colour and generaJ exprcasion of 
the fa<-e, tbe form of the features, the presence or abeeocti of linea or 
wrinkleH. and rciuark if the uorot act in rr-Hpimtioii or the eyelids close 
incompletely. We can bcKiilcii iiotic« the nttituile of the child, van count 
the puLte and respiriition, and can observe their decrree of r^ruluify or 
any deviation fn^tn the hmlthy ntnte. Even if tile <^liilil be awake, max^ 
o<f Ihcue poiiilM can 1h> notic<tl if ne nppronrh quietly and do not speak to 
or oiler to touch the patient. Any movcmeotH he may make at tlu:; lime 
in hJH rot inUHt receive due attention, for tbcy often coaTey very valuable 
iu formal inn. 

TiicHt^ point^t baring been noticed, tbe temperature alionld be taken. 
In doing this, if tbe paticul be au infaul. it i» dei^intblc to introduce tbe 
bolb of tbo thermometer into the rectum, for id tins early age the dilFex- 
ence between tbe internal nnd external tenijieraltu'e uf the btxiy is oEteii 
cotuidomblc. The child should nest be completely stripped of hisclotbea. 
Hie stafe of bis akin cim then be asoertniued, notiag the pruacncc or 
aboenoe of eruption : and a cnreful eiandnntiou must be umde of the 
abdomen and ebest. If the child low hia temp4>r at this lime. Ibe quality 
and strength of his i-r>- should be remarked. At tlic end of tbe visit the 
gums, muutli, and throat should Ih- in»(]X:cled. and if oiiy of the child's 
water can be pru<-iin-d. it should be exaiuined for albumen, aud ite denatty 
4UkI degree of acidity tmcertauied. 


After tliU rapul sketcli of tbo metlioil upon wbii;h the cUnicnl f^xamint- 
' tion of tbc uifiuit. nntl young rliU<l should lie can<luotcd, the (rhip.t points to 
wliidi att«iitLOu tuiuit be ilircctcil may be couaiiiercd mure io dohuL 

In tlic n<ivf-bom infimt tlit- Itnl vf the faa: ixaxaifAsjiXcXy after birth is 

dull reil. The redness, however, soon begicB to nubeide ; in a dny or 

'two the coQiplexiou assumes u slight yetloiv tint, and then pnssea into its 

. normal ooloriu^. Tlie jellow tint and its disgnosLB from infAutile jaundioe 

BUS rvferrsd to eUewbere (tww Jaundice). 

The clear fresh L-ompk-xioo of a hcaltli^ baby or yoon;; child is familiar 
> to ererr one. A lofts of '\\» purity and cleamehH in one of the tii-nt inilico- 
I tiona of digentive derangeiiieut The hce Ix^i-ouies muddy- looking and the 
upper lip wltitish or bhtiali. Bhieness of the upper lip in fas\y life vt 
& eomrnon sign of Ubour«d dif^estioo. In sonao children difficult digestioD 
ia flhowD by an earthy tint of the face which »preiulH to the forehead. It 
^»peaiB a idiort time after Che meal and may latit Hereral hours. In chronic 
bowel (.>ouiplainta the earthy tint is confitnnt. It ia eoinnton in caiieH of 
chrouic diurrha.ik in thu iufunt. uud if at tbu sumo tiiiic thuru is much 
ewaciuiiou. the dcmngement is likely to prove obHtinato. In s^>i)hiUM the 
prutuiuent yaxtB of the fiiae — the nose, olieeka, chin, and forehend -aasuine 
a swarthy hue. In lordfloeons diaenae the complexion is iwcidiarly poUid 
and bloodless ; in rickoty children whottc ttplcenH ure greatly enlarged 11 
liM a ffrtMsniith or faint oUw ciixt : and in cyauoxiti the face ham a clmr- 
■eleristic leaden tint, the conjuuctivte are congested, and the eyelida and 
lips thick and purple. Lividily of the skin round the month and nose 
with a ptiqile tint of tlie eyelids is common as a result of deficient (U'l'ntinu 
of the blood. Id severe cases tlie choeks at tlie same time have n dull 
whit* eolor, aud the 8;)-mptom is an unfavourable one. In Uie apEiamodic 
sttfB of whooping-cough the fane loobti swollen its well as lirid, the lijis 
and cnrelids are puq>lo and tliiek, and the conjanetivm aro congested and 
often bloodshot. 

Id addition to tin- ivctual tiut of the face the general oxpresiion must 
neeiTe attention. lu a healthy bube the physiognomy denotes merely 
rieepy content, and no lines numc the Kmootli uuiform snrface. Pain is 
indicated by » coutradiou of the bro^rs which wrinkles the skin of the fon>- 
htwl. This ^» (.-specially uutimablc if the head is the Kent of nuQering. If 
the pain be in thu nbdout>u the noee often lookti uhai'p, the uotitrih) are 
ddatM, and the child ilraW8 up the corneL-s of the mouth mth a peculiar 
expresdon of distress lu every cnse of aerious ditteaae the face, even in 
r^KMU, has a hftf^gartl look, which must not be diarogarded. If this b« ac- 
c oB ipa a ied by a bollownam of tbo cheeks and eyes the re«ult is a ghastly 
expKsaioD nhieh cannot escape attention ; hut a distroased look may be 
wm in tlte hce although there is no Intu of loundneaa of feature. If this 
be the case, even in the abHenci:- of striking symptoms, we nmy confidently 
predict the onwt of serious ^Lveasc. 

Often nn inxpcctiuu of the fucc will help us to a knowledge of the part 
of the boily affected. Mnuy years ago M. Jiidelot painted out certain liueti 
nr furrows in the face of an ailing infant which by their position indicate 
tbo seat of tJie derangement, thus : 

Tlie orvulo-tyjvnuaur Unit begins at the inner cantLus of the eye, pasMs 
thence dowiiwanls and oulward« benonth the lower lid and is lost on tbo 
dMsk a httle below the projection of the mnlar bone. This line potnto to 
disease or derangement of the brain nnd nervous system. 

Thl* nivai hnc riscM at the uppor pnri of the aia of the nose nnd passes 
dovuwnrds curling round ttio coi-ucr of the month. This lino is a constant 


fcfkhire of ebftominal luiBcluef, and is norcr nbeent in cases nf gaetro* 
iuk-Ktioiil <1«rangeiD0Dt 

Tlic IMal liiic Iwfpnfl at Uie angle of Uw month iuhI ninii mttwnrdB to Im 
lost in the lower part of tUc fucc. Tlii» ia inoro Bsfaallow than tlie prpicDd- 
ing. It in a burly trutttniurtby ftigu of diseaae in the lungs iau\ tar- 

TliftM lines have a duitiiiot practioal value lUid abouM be olwajD otUmiled 
to. Via lUiuuld alfto uotioo if ttio eveUils cIukc (.■ouipli-k-l}', fur iuiperfecrt 
closure of iUh UJb tluriu;; tile«p is a t'Oinuiou sign of weiUcup**, Moremer, 
it must not be forgotten to aacertain the condition of tbf pupils aod tho 
pruHfuce or aLseDO« of s<{uiti(. The value of these »viiiptuiiiH. imd of 
oth«niL-oiiuectt*d wiUitlie tjt^, h referred toelsewhera (see ptsfi-v '24il) Tlie 
nan><a laust uot Iw fur^tieu. If th(»y (u^t in rospimtioii H\p iiMivement is a 
otjiunion ancoiiipaiiimcnt of lalfouiL'd breiithing and ofLcu indicates an 
itniwidiuiout to the i-f«iiiraloi^- ftiitction. It may. Itowei^ r, be pr««ent in 
KtuifM n li«?re thure is no iwnscious dyspocMi, attd l» sonietiiuoK !»:vn in lain- 
pic p,>-rexia. Even th« »bitp« of the features must bo Attended to. An 
f lori^l«d bead mtli aquarc fnrehead and small lower jaw lire rhamcteriBtio 
of riclit'tH ; a lirond flat bridge 1o tbe nose, ej^ciiillT if cniijoined will) 
proniiiiruce of Die forctiead nid nb»eDce of eyebrowa, Ruggosta syphtliit; 
uiid a, bi>; f;Iobu]nr htttd sunuounliit^' » hiuuU face and httlo poink-d duu 
iiiilinittrs lumiintakably chi-unic bvdroccplndiift. 

The attitiuie of the chilil ns be lit^n in biti cot is not tti be oTcrlookod. 
Somvtinteti it is «baractcnsttc. A li^idthy iiif&til or voung vlidd. «veu if 
lyiut; on LIh buck, iiicUiifS tu oir^ ttidi- nud lunis liis lit-itd so tttt lo briu^ 
tbe L-bt't^k ill c.'oiit]u.-t with tlie pillow. If u baby htt found lyiij^ motioulMis 
on bia back, with closed eyes and face directed straight upwanis to the 
ceiling above him, lie ia probably tli* Md>jfict of eeriotiri iltM'aae. Tliia jki- 
sitiou miiy 1>« sei'U ubt^u tbo c-ltild in uucouscioue. as from tuVten-uliir 
tneuingitiu ; or in profouudly depn^tntcd, a» in aeut« iufbumuatory diar- 
rhtea. If the child he on his aide with his head (jRatly retracted on hia 
ahoiildei's, it ia a auspicious aigii of intra-crmiial diaease. If in auch • po- 
sitiou Uie breathing is audible and hoarse, tbo case is probably «ie of 
lacyngitis, or there is eomc imuedimeQt to the passage of air through the 
glottis. If tlie patient be fniuid iii bin oot resting on bis elbowH and knees 
with bis forehemi buried in the pillnn-, or if he Kleep tying on his belly, 
there is no doubt Abdominul diar^nifort. Tbeae po»liona are eommon 
^Hlb rickc-ty children. If the cliil<l preHH liii' cyt-Iidn ii^nuntst the pilloWi 
turuini; partiidly uu bis cheat, we niuy HUHpeot iutoleninL-e nf light. 

Healthy iiifauu and ohildwn a!f'epj>erfert!y <piietly, Fretiueut turn- 
ing of the l»xiy or lwit<^hiug of thv uiuai'Ii^m gtucntU^' indicates feTerishDeaa 
or di^cHtivv dL-raiigt^'iucnt. If the child move biri lieuti coofttantly from 
ui<le lu side uu the pillow, he in probably aijiiuyod wilb paiii in the bend 
or ear. Frequent oanying of the hand to the foi-ebead or side of the bend 
tuut usually the samesignitlrAnce. If the rhild repeatedly 6ex the tbiglia 
on the nlxlomoo. and cry rioleutly tu sudden paroxysnis, be is probably 
miffei-iug from oolie. 

The cTfi of the child is a symptom of oontdderalde uaportonce. It is 
usually elicited by hunger or unaLsineaa, and from the mamier of crying 
we eon often gather eonmdcntbln information. A hungry infant in nioi.t 
COBOB clenches his bjinds aud tieica his Umbs — both onus and legs — as h« 
utteiB hin compliuDta : nitd will oftuu continue to do i«u until hut deainui 
are satisfied. Thirst may nUo Ite n caune nf crying, and may lie suspected 
if the child sndcB hia Upa repenUHlly, hits a tlry mouth, or has been suffeiv 


iofl iroiD purging. If h* bp tortureU br colicky pain, the cty in violent, 

ftiM iiarDxysmal, and is accompanied tiv uncoet^' uoveineDls of tlj« body 

and jerking of tlw lower limbtt. Tbe hv\ly is nlsu full um\ linrd, mid there 

i» ofu-ii n l)lu« tint round the mouth. A lihrill tM'reHiu utLured nt intervals, 

the child iyiu;^ in a drowKy utate with ulotwd yytui, in (ni^geHtire of tuher- 

cular uieniiiL.'itiiB. A constant ujuippea»al>lo screaiiiiii^ ifl oiteii the coiim- 

queiK^e of f-iir-fkche. This jKiiiiftd iillVtion ik rerr roiiiiDon iu iiifnnl-s. uiiil 

should bo nluays) HUspr'cN-d \( tlio lAm«ntatiou8 contiiiui^ nitliout iiit«niti)^ 

tixm, ktitl tho tfliild (ro<|ncutly pressM the side of Ui» bead oj^ainst liitt 

'a breast Tlje pnin of pleurisy nill ali»o cansc Tiolent crying. In 

cnae presmn'n upon tlie tdile* of tlio <^hftst, an in Ufting the child u]), 

■n erifloiit incrca»o iu hix siiiTorin;;. Any alteration in tho quality 

the cry uiuat be uuti-d. it aiuy bu huurso in a youn;; infant from iu- 

rtted sypliilis ; in an older child tram lanrugitiH or enlargement of the 

ibroochuil -^liiudfL 

Iu a lioailhy infant a cry in excit«d at oiicc by auythiug whicb ctmactt 
ira dL-i'onifort or incouvenienfe : tlicrefoi* the abn^iuf iif rri/iiig in n 
tyiupltini vrhioli ithoidd idwnys rutt^ive du« >ittf?nliott, lut it luuy betuketi so- 
diaensp. In infliininiiitory nffectioiia of the Umgs, in pulnionjirr col- 
lajiea, and in ntlvaiiced rickets where the boiieit are nnftened, n child nil] 
bear eniiHideiiLhle diac-onifort without loud (;(itiipl.-tinl.. for \n< lui» n prcwti- 
iag wmt fop air aud dnr*' not tiold hw lif**«l.h to eiy. So, also, in severe 
diatrbuea or any otlter iUacss which cantos i^reat reduction of etren^th, the 
child, on account of bia weidinesA, crieH little if nt all. In catmn of pnv 
found weaknm he will often be noticed to dmw up the comers of bis 
^^ mouth and wrinklo hit browti as if to cry withont mannf; any sound. 
^H Iu the 04^'! of m-iiig toiu^ aro copiously 5ccn.<ti?d after the age of three 
^Hor fonr uiutiiha. In Herious dineane, howBTer, tlie lachrymal seoretioo 
^Hoften foila Therefore the aba«nce of teATs must be tolcea to indieate con* 
^™Btden»bIu dooj^r. 

r Tbe /j'l/xr iu the infant nui seldom be count^nl, except during deep ; 

and even if itti rapidity croti bo luict^rtaiiied the information thuti derived ia 
of httle value, xhe rapiility of the pulse iu infancy is coiistuuUy varyiu;;. 
Tlir leoat movonieui excites the hoi^rt's iirtiim, and mctitn.1 emotions, such 
u frif^ht or an^>r, fdruout doublo thv nipidity of ilw oanline coutravtiuus ; 
w that, according; as to whet]i«r the infant i« awake or iislcnp, is ]}ei-fe«tly 
qaiei or haa jnat moved, thn pulse nmy vor^' fnrai between HO and HO to 
liXt or ISt). As a teat of physical vigour in bahi<>s the piilite in wortlileKo. 
In ihi« roRpoct tjio fontAnoUe in of for pr<'ater \-ftlue. In intanta under 
twolvv moatlui old a idukint; of the (ontaaclk- isn sure aiKu of reduction of 
the sLrvufjtb : und in tou<hinK a child of thia hrb our lii-st care should 1>l- Ui 
pan the tiii}^t-r over tlin top of tlic lieiid and nacertaiu the cnnditimi of this 
pttt of the ukulL Jn WMit«d btibictt the foutaui.-llu often furmii a cup- 
eha()e<l depression ; and if the Iohs of flcsb iu very rapid, os when a pro- 
fincdnun occcnt from the boweK the cnuiial bones may often be felt to 
orcriiQ) slightly at the anturen. Kxceiei of tluid iu the akull-cavity or n hy- 
poKnic state of tho brain i-.iu;>c« bul;riu^ tmd tcuMtuL-m of the fontaitelle^ 
Uoleaa nry diittendMl the meuibnuie ui not motiuulewi. It can bo M-vii to 
iBoTG with reapinitioa and U> sink appreciably as air is drawn into the 

iftPT the iieri<Hl of-iufftucy has passed, the pulse becomes a far mora 
IraMwDrthy <piide. Durin^j: fileap it is fifteen or twenty beiitM olower than 
Hvxibfi the V'-'ddii^' &tate, and mav then be ocoaaioually irreK^iliu- in rhythm 
reiQttleuU Wheti the child wakes the pulsations 



(TCatK* in frequency nnil iiHiiAlly ri)M> nlxive 100. If at this tigt Uie pul^ ia 
foaiitl to full lu low lui liO or 7IJ in ii I'liilil nliu in not uilwp, uul to tDtomiit 
complstdj, th« xign inny 1>a Ki^ili<*ant of tab^rrular BMniDgitiB. Thia 
tnatLDr ia elaewborc rcftrrMl to (act impc 359). 

Tbe reKpiraticiRs HhouM l>e hIwsts c»untal lu DPw-bam infsnU their 
nunilicr ik about 40 or pnrliapH nmre in tlie minute. Uat tike brentluDg 
Hooii bccomvti U-w nipul. iillbouglj for tt k>ng liiu« the mo^'emttQts oro : 
trwfueat tluui ui LIm.> wlitlt. »ml vvtn after Uk st'cuu J ycmr nro unuiilly over 
20 in the tuiuule. Tb« uormul aT«ni(;e is ilt^cult to lucertuu. for like 
tlie ]mlsulio>ia of the lieart the breatbiog varies greeiUv iu rajtitlity. It ia 
nitliiir nli>n«.r iluniitr sle«-{> tlitiu wLeu iLc (-bikl ia awkke, but itt apt to be- 
ntmu iiiun* burrioil tiuiii slight CKU)i«e8. More iiiiix)rtatit tliim tlie ictual 
r^iiJity of oilbtr t)ie bn.' or the ptil)M> in tli» nitiu tLe two bear to 
oDC onoilier. If Uiv bfrdtliiiig beiwtite m]>i<) out of proportion to the 
puUe, tlie <1i»rrfiKUit-y 8lioiil<] l>e oirvfully uotei]. The nomial ratio ts 1 
to 3, o)' 3.5. If tliix prupurtton li(>i^iui:« f^nmrly iM-r\'(!rt«(I and wv Ami uno 
respirator^' moTeoieut to ofoTy i-<Ko b«»t» of the imlw', we should 8u<^pect 
ihe presenre of pueumnnis or of pulmouniy coUaiwe. The repuIajTty of 
tlie nwpimtiou m nito to be noticed. A eiliffbt irrc^lnrity, edpeciall^ in 
foroo, ia conunoD in inbrnta; but if th» brcotJuDs bewme miirkedly irrvfi' 
ular, the n-niptom may bo aii impcirtout uoe. Frcqut^nt licavy iu^'Iih and 
long pdUHeM. during whicli the t-hest is jjerfecUy niotiouk-ss. arc very ausjii- 
uiousuf tubercular meniugitiB. 

llie {<i"peraturf of the uhild ought nlwayii to be A«certiui>ed. It raust 
Ite taken w-itb cnrr. Iu u hcallby iufiuil tlie tem|>enitiire of the rectum is 
about 99°, and in fuirly I'oniilaiit ttiruu^itotit the diiy. It riseti half a d(>gree 
or HO towards the eud of digestion, but a miu-ked difference Iwtween the 
luoniiu^ and evuuiu^ t«tii]>erattire in not nottct^d in a healtlir baby who 
receives proper attontion. According to Dr. Scjuire, if the bodily heat is 
foiuid to raty cousiderabty at diffvi-eitt tiniett iu the day, the symptom 
shoidd Ru^fgest neglect on the part of the nurse or dehcacy of coniititutiou 
on tlie port of the child. If the iii^t be kept too long without food tbe 
temperature falls, nnd will then rise s^^un considerably after the meal. It 
nlno appears froia I>r. Squire's interosting obeervations upon yonng babies, 
tiiut Uie tempcniiure ia rather lower during nleep than when the <-hild is 
avnike. Even aftei- tlie age of infancy tlin temperature ia subject to fr«> 
quent i-ariAtiona from tOight causes ; and in yoim^ cjiildren mental emotion 
vfill often induce ii dt^Ti-f of fcvir which iiiiiy b« a «jurc« of ]K-rple)tily. 
In children 's bDHpiLnlH it is n txiniiuuu observntion that the bodily heat on 
the evening of luliaiaiiion is high even when the dlaaase is not one usually 
attended with fever. 

On account of tht> excitability of Ihti nenous iTi-steni in early lift — a 
|)eculiarity (J childhood wliicb linu been before referred to — ehildruu are 
very subject to what has been called " irritstive fever," i.e., to a foiTn of 
pyrexia vthioli reault^ from fretting of the systeui hy \'arii>ns sources of ir- 
ritittioD. Dentition, ns is explained elsewhere, in a freipient promoter of 
this form of febrile exeitenient, nnd n pyrexia indnced by lliis moAna is apt 
to compUcato deraiigenieiits ordiuiuilr iion-febriJe and Im a ciuiso of con- 
fusion. So, also, irritation of the bowels by scj'ltthi, indigestible fooit, or 
pimisilie worms, is a common cause of elevation of lem^x^ralurG in tlie 
youn;«. The febrile movement resulting from the presence of a li>ciil izxi- 
tonti like other fnnnt* of pyrexia in rbildliood. is generally reraittml ; but 
tlte mmiKsions are not always foimd at the Miinio ])eriod of the tweitty-foiir 
hours, Xheie U not always a foil of teuipcLittut'Cr iu the uonung and a i-iae 



Dight. Miie of tlut poRiiliariUos nf tliin form cif foloiln (lialiirbftncp is 
lie irreguluritv of tbo Cwor. lu u yoiui;; cliikl a ttiiupecaturb liigbcr in tbe 
lunuD); tbuB Ht ntj^bb sboulU always HUf^i^i'sb somu rctkx cuiuto for ibe 

It is vetT important not to neglect tbo nse of the thermotneter in judg- 
ing of ibe hvnt of tlu- budr, for uut only lm tbe h»D(l veiy deoeplivc as a 
guide, but tbe itkiu of tii«< pati(<iit uiiij iipptmr to be cool altbou^h tbe in- 
Lem&l t«in|>«irnliir« ia sererBl degr«(^ii nbon> tbe normal level It in not 
nncoiumoD iu ims^h of inflAuuuatoi-v iliarrbot-a to fiuj tbe «xti«iiuti«fl so 
coUI SH to require tbe applicatioo of n iiot h<>ttlt\ wbile « tlieruioiii«t«r 
, placed in tbe rectum rfgigteni 104' or 105'. SmiKitiinesiu youug children 
"i* pyrt-si* will roocb o very higb level At tbe ernl of an attack of tuber- 
meRingitis tbe len)}>emliirn in often 100'^ or 110" ; and the name ile- 
of feltrile beat ifi oemuiioiiiLlly HPe^n in noiicnt of aoute gastro-intestiniil 
iflitmmtUion. Iti eillter taw lb« srmplom liotakcna ezt.reme dniigtr; 
Itbou^b it mtut ntit be txinrludcd tbat Llio illiicHK will iuvWtubly proro 
kt. I bare knon-n a bitbr of n few weekH old riit^over niter its rectal tem- 
itore bad risen to the aloi-tiiing beiffbl nf 1(1!:)'^. 

Sometimes instead of nii elovation tiie tberiuoi»el«r may sbow a lower- 
ing of t«mpcmture. In iiifiuib* any reduction iu tlK'i biKlily heat in uaiwUjr 
a sign of defit^'ieiit ixnirinbuient In u baby exbaiiHtCMl bv dirouic vomit- 
in;? or piirf,'in(j (be tempcmttire in tbe rt<^tuiii mav bo u^ uifthcr tbaii 97''. 
i» of ooiirse an estreme case ; but a leHHcr dcpreeHion in often found 
iufoiitH inmitliciently>e<l, eilber from wnt«>ry brenflt-inilk or an 
liable dtntarr. Af^in. in oonvalesoonefi from a^uto diaenso tlifi tein- 
lf« nauflUy lynviins for 6ome days or even w4?«k-t at n lower lot-el than 
tliat of bcalUi. Tliid pbononienon iniiy bo often notiot'd after tj-pboid and 
the other eruptive feven*. 

before leaving tbe tmbjeet of temperatare, referfrne« may be mode to 
tLfl pyrejiia which Boiacliuit-n attends rit]>id i^runiJi. 8<-v«riil <it»rw hxw 
tome nudtr my notice in wliicb ^ruwuig •pi\n were exL4tiu<f great atixiety 
bf a ]ierBiBtect evening tem[)eruture of over lUtl^. In oue Bueb eu»e, a girl 
of twelve hod been kept iu bed for ti%'e vreeks and treati^l for typlioid 
feifr. tbe girl all tbe time begging to get up and declariut; lierftelf to Iw 
jierfeotly well The jitttieut was bronglit to mo from the i*ountn,- for *n 
■■fni.ion, Ofl tbe tetii])erf»tuve for nix weekn bod varied erorj- ni-jbt bet\veen 
'-*:► and lOO.ti . 1 c»tmine>d tbe child i-arefullv and could find nowhere nny 
B^ of (liseasp. She looked healthy and was said to be growing rapiilly. 
I wi^irdiiigly adviwd that nbc should l>e no lon;,'er tre.itett na nn invitlid, 
I be allowed to got up, be put ujkju urJiiiiLry tliet, and bo »i-ut 
lis posriblo into tbo ojMfn air. Tliis w.i.s dune, and at tbe end of 
% tortu)|::bt tbe tein|jerat.m-6 Iterume noniiul aud did not aflerniirds rise. 

Having obtaitiud all tlie information we con without unneceeenrily di»- 
turbtug tbe patient. w« nbould nest, in the aus/b of an infoul or young child, 
hsTp tlie doUie^ eompletely removed 80 oh to be able to make a tborongli 
txaminaliou of the Hurbi(.*e of tbe bojy. We con thus notice tbe condition 
nf thfT akin an to texture and etoRticity, and reniark the presence or ab- 

- -If of eniptiona or signs of inlliunmatory swelling. In a healLhy young 
. M. ib<-ikin isd«licnl« and »'>ft, nndofn beautiful piriki<sli-whit« tinL Hit 

'■-■'■ i: ■ iiid have an earthy hue, the cbaoge i-* Buspii-ious of chronic bowel 
Qimplamt. If tbo akin ih wanting in elasticity, we should suspect tubereii- 
iwa or renal diwaRe : nnd if the kidneya bo performing tlieir functions 

- ;■ ffectly, tho elcin may be oftf-n «eon to lie in wrinfckd fiilda upon flie 
'i-i 'meiL DrysAsit, with a dingy hue of the skin. i» aUu common iuttomo 


foiiuii of lifjtntic (lisea-se, and occjuiionally in chmiiit- tiiberrubtr perikiaiti& 
At this {Mui of tlio exAiiiiiuitton, anv Higii of t('»(l(>rDciw ^tber g«upral or 
local should r&c^i-vo ntU^tion. Tlif^ sluirpor en* of pMU is usually to be 
reiHlily tlititin^iMied from tho 'ry of irfitahiliW or unger. In hrkoLs 
there is general teudenieMi whicL makeH all gnrpfltnire painhil. In jklt'iinBj 
prMKuro upon tti6 sidcn of tlic> cbeBt, as in lifting; thi> <!liild U]t, in a i^iisq 
of acute Hufftirm^. Hoiuutiui«B Bigut) of looal tc-udcruoia) nui he diM-over«d, 
Nurh an may accompouy the fonuuLiou uf luattt^r iM-'UGOtb tbe fturfM« ; or 
D^&iii, tdifitlit t(>ii(ieraeHS of a joint tuay be the ouly indicAtion oi rboiim«- 
■Uetn iu the <>hiUI. 

Tlio nttentiuii kIiodIiI next be directed lo the re^mtttort/ moomtentg. 
■In healthy yuung rbildren r«^ratioii a chiefly dii^ilingTnaUc. Fnrrible 
' raoTemeut of the thunurie walte tx n «{;;» of laboured breathintJi, and if a 
cuusUml xymploni of Iifoncho-iiucuiiionta. GtTot fetvAinon of the loner 
pKrId of tbe oiiest wtggratH mi impediment to ttir entrtuioe of ntr tuto tbv 
lungK. If »t ooel) Lnspinttion there in gi-eat reocwion of the cjjit^strium, 
the lower port of tb« sternum bciut; forced inwnrds »o as to iiroJuce a 
iletp boUnw iii tlie centre of the body, thu ohHtmcUan ift probftbly iu the 
tliront or Inn-ns. SupL b deprendoti ia neeu in tlie cnite of retlx^pbAn u- 
^,'fiil abftC(>t!)«, in 8tri<iuIourt laryngitis, and diphlfacritic croup. If th*» clje«t 
fall iu liitenilly ho tm to prwluor a det-p groove, nimiiu^; dowDwurda nuti 
outwarda at each hide uf the chest, while at tho aame time a liorizautol fur- 
row (omi at Uie junction of the chest with tbe abtlomen, the itu|ie<Iinienl 
is due to mftemng of the rib«. lliiH is chamcttrhatic of riekct^ 
Komi'liuiL-a iu I'hildreu wtio mifli-r from enlarged tonsils ii cup-sluiped do 
pn'tudou 18 H^u at the lower part of thu slemuiu. It in ri^bt, however, to 
any Ibat this defonnity is not oonfined to oliilJreu 1^■i^b enlarged tonaila. 
I have Heeu it wcU iiiiukeil i!^ paliontt^ in vrht>in the pliarj'ux won perfccUy 
noniul. and in whom no impcidimenc appealed lo exist to tlie eutmtire of 
tur into the lunga If the vhost movti more fntiy ott one side than uu the 
other, wc sliould euapect emve mischief on the side on which Uie move- 
ment is faampci-ed. Still, in the child serious diHeaae of the cheat may Ite 
Iproeent wiliiout our being able to detect any atieh ditTen-nce. Kven in 
' «ftge8 of ooptona pleuritic effiiiaon, no imp*in»eDt of movement in the in- 
tcrooalnl »jxu'e» of the affected aide may be vimiblc. Marked contraction 
of one Kide of iIie> tbonix with curving of the spine ia aui^stive of a late 
Htage of pieurisn-, or of an intlurated lung. 

Xu thu liealtliY child the aMumcn luoveti freely in r«epiratioiL If it be 
niotionlea*. tberefore, an tiifl:uiim»tor>' lexiuii of tlio belly should be saa- 
pected. If (he HU[wrf!cial vuiun uf tlie alNlonioii an* tiniintiinilly viable, 
the symptom is sugj^eetive of iMiiie iiu]>ediiueut of tJie ahdouiiual cu-<.'ul»- 
tioo. such sa would he produced by eular^l mesenteric glands or liepatifl 
iliaeaM. In young ('bildren tho Ixdly is always di^roportiouately lar^ 
Its size is due to sImllowneKH of tho jicb-iK. to Dtilnnw of the dinphrngm, and 
to laxoecB of the muscular walls, which yield before the preaHirtt of the 
ilatua in the bowels. In some healtliy infanta tJie abdomen is mnt^h larger 
than it ia in otheniL The <lifteTenre ia prolMbly dne in moat ca^»e« In an 
exaggerated amount of flntiu) formed in the buwela tluriu^ dij;^ttuu. The 
size of the iKrlly from this muse iM>metime« jiUnuH luuntnts ; and it i« not 
uucummon to be cummlted nith regard to this jioint in tbe cass of young 
chUdren -who are in even,- itfpp^-t ]>erfwt]y hwiJlhy. Often, bowcvt-r, the 
cularKemeut is due to iiivxcu.-it- in inx*^ nf Ibc liver and r>tJecD. to the inrL-a- 
*'□!'« of a growth, or to tu:i-iiaitdiiiiou of tluid iu the j>criiouenm. The «ize 
of the liver and aplctcn may be ascertained by plai-ing the hand flat upon 

mIoihod. Uie fincers poiutiug to the cliest. uid presaiui; >^t'iitly mth 
mvr tip«. In tliM nay with a. little pntctice tlic edges of LUew urg»iiH 
can KadUv he Mi. At thit «aiiio tiuio^ LI tli« chikl be Dot cr^Hiig, wd ran 
iwf»'i1i>iii the (Ictji^ree of tetisiotj of tb« abclomiDtU n'aJl and the preaeucc ur 
afaaenoe of fluctuation. Abaiirmal tension of the pnnet«8, especiitll;^ if it 
h» mora mai'ktwl on oae flt<l« than on the other, is suggestivs of jx-ritouttiH 
or aloermtaon of Uw boveln. For the meiuitt of diagnosis of tlio eovenil 
conditions which give rixe to abdominal enlargoment tbo reader in referred 
to th*- cliapters treatiuR of these mihjcctii. 

If, iiisteiul of being diHteiide<l, the belly is markedly retruitcd wo Imve 
renBon to KuitpiM:t the pn-sonce of tubercuhir meuuif^ilJK. To uxiuiuno tho 
obdnminnl or-^iUH iit iill witiriftietorilr thu child inu»t liu uu hiM bnrk nitli 
bin tuAit and HbouUlers raised by b piltoiv. Tlie mulLer or nurse should 
nt upon the bed by his side, and Uie prictitioni>rHhunld take rare tluit the 
luud be applies to tbe belly Lh vr-anii and lUx^^t not prenH too abruptly- 8u ii^ 
to give pain. Tliis part of tlie exaiotuation is iiaii.iUy submitted to uithout 
oppo^bon it the child ba liumoure<l and cheerfully tnlkt-d to. 

Even an exauiuatiou of the choet can generally be undertaken without 
tear of ^lure. Infant-i, tut a mle. seldom ^i^e much trouble ; and if tliero 
is aoy Htrioiw ditt9its4> prenent in the !uag, they are too niueb oceupied by 
the dmkIs of rMpirntion to ifpnre timo to cry. In cnrly oliiltlhood th«r« is 
more rcueon bi fur oppocdtiou, but with pationco tli#o)ULiuinatLOQ can uau- 
atlr tie curiecl to a. sueuesoful ivaue. A Btethoecope in seldom objeote<l to 
if it be hriit plnoMl in the cliild'a band and ooUed a tnuupeL For fiirtlKT 
miyirks upou th>t< ttubject sud tlie pecuharitictt of the phyi»iad »iiiiiti m 
childhood thv r^^uiur ia n.-ferred to tiio Hptcial uhuptcr ou L-xiiuuiiutiun of 
the rJiest in i;liildreu. 

Inspeftion of the mouth and throat should be (dways deferred to the 
end of the visit, an Uuh port of tlie exiimiiiatiou invarii^bly pn>ltire4 evvxy 
nuinfmtation of diaplen-sure. .Vn infant will often pnitnide liis tou^'uu 
Vbcn ffentle prassnro is ninde npnn hi» i^hin, and a linger cm\ be usually 
pwed orer hu gums without eif^u of oppmtitioD ; but to look at the throat 
we an* forced to depress tbe tongue. If any nymptoias are noticed rerjuii'- 
ini; tlie Operation, every preeuution sJiould bo token to render it mieeeftsfnl. 
Hiv uui«e eittiug iu a low chair facing the window or a good himp, holda 
the (duld sLnii(^t upou hor lap with his back resting; n^tuust her chest. 
!Jhe Uieii with her arm throwu round liis body preveiitii the patient from 
rhanjpng bin position or misiu^ bis hands to his mouth. At the same time 
aoi atteudaut »lAuding Itehind tier witli a bond on each side of tiit^ cliild'it 
fan holdfl bii4 bead Lii a convenient position. Matters beiuj.' thuH arnuiged 
it is the prartiliouer's onn ftmlt if lie do not obtain a good view of the 
fuwee. c inuness is absolutely necessarr at thia poiut. Any other plan ia 
•qoal^ annoying in tlie patient^ and in almotit certain to end in failure. 
Brfofe tuspe4?tin<; the tliroiit, the iti<Les of the neck Kbould be oxauiinod for 
tvUeoce of swolion eerricnl (>land% 

In BoiDC casKV it is important to ascertain if the child tabes the breast, 
aacks the bottle, or drinks from a cup with ease. In infantile tetanus the 
owm Aict that tbe patient is able to swallow enablcit iia to Rpaak less un> 
fmrambly of his cluuioee of rocuvcry. Iu eattes, too, of apparent titupor, if 
tbe child still contiaue to take his food the i)i(ju is a favourable one. If a 
ctold lie suffering from acute lung disease, he sucks by short snatches, 
AHiping at frequent intervals to di-aw his breath. A 8yi>)uhtio child with 
oodusinn of the norea sucka with great diflividty. na bid iio»e ia uaeleas for 
nqvator}- purpoaeg and ill air haa to pa^s through his mouth. An inEut 



vith bnd tLruiJi \in» much pitiu in (Irnix-in;; tlio milk from floreneoB of liiii 
iiiuuth and toQi^H. nnJ uiar refuM> liiit Itottls iiltog«tiici'. If tbe tiut»i li« 
Rure the child sinUtHwrx iioiBily. iukI often ivliui)uii>lje8 the nipple to oougli. 

Ia«11,v, tbfi pribctitioDcr slioul<l be careful to inspect tlie vomited lUAt- 
ien ami tliscliftrges from t\w ImwpIh. ».h itw dehnnptioD of their appeor- 
Aitce givvu l>jr th» bmt niu-Kes in rmvlf to b« tnisteil. The varielteH of 
loose stool are cleeirhere coiieid^^nKl. Kooil romitod eonr from tlM stom- 
nrli in<liratra a catarrUn] hUI^ of i\ta puitric tuuooiiH tncnibnuie. Murli 
miK-.tiH niixi-tl viilh tlif fjci-ted iiiittt''nt is al»o a hi^i of the Nimp roDtlilion. 
Vdiiiiliii^ iit not, liowpver, rIhyivm a itriiiptnTa of distn^tM. .Vn infnnt vho 
has swiUlnwcd too larjic a qunutitr «>f milk, or bno tukcD his bottle too 
luistily, ^-i!l oftrii eject a jiort of tho meal ; but in Biirh a case there H 
nothing nfTcuRiTe nhoiit the mntterH thron-n up and the child himwlf flbows 
no ngtx of diitn«a. 

In the treatment of diseoHe in earlv life tho actual hdmiaiBtntiou of 
phyidc in of less tmpui'tiuice tluui a careful re>fu]aliiin of the diet and at- 
tentive uuraiiig. It is the duly of the practitioner to Bee that no impedi- 
ment ia tlirown i» the way of the proper workiui; of the rarioua functions ; 
that the 8toritac1i is Mipplied with food it can di^et«t, iliat tJio akiu, tho kid- 
neys, and the bowebt are encuura<^d to carry on their duties as eonnncto- 
rtcti, that the air of the rooia is kept pure oud freqneatlj rettewod, and te 
morenver inaintainRcrat a suitnblp t^tii]>emture. 

Febrile attaekx are verr ronimon ii) childhooil. and if the temperature 
i« hiffh (i>., iilunt' UK) ), which it mar hfi tr^ra very xlii^bt nrtl tnuiaient 
cnnw.'s, tbo rbild should Ix; cimtiiiEid lo Iuh bod luid kept tlicrc nit lunj; as 
the p;iTPxia continupa In all fonna of fever the child should occupy a 
large, well-ventiliitcd itioni. Thia should bo kept at the tenipL'ratun> a» 
nearly na possible of 6i>'. and evert' care should be taken to miiiutiiiii the 
nir of the rrxim frcith nud pure. Still, no diiiupbt luiint be aliened. If 
tho wiiiiluw it; open the palifiit unii^t be sirnipulouMly protected from all 
currents of nil*. No difM^harges from the body, soiled linen, dirty plntes or 
ilifllifti fthoulJ Ik* allowed to remain in tlic eick-i-oom a uiomeut longer than 
in nece»Mirt- : and in the case of the infectiouti feverx tho exereta must be 
disinfc'f ted at obi>o, and tho soiled sheets and otlier linoD ste«]M>d after re- 
moral in a tub of water containing carbolio acid or other disinfectanL 

All noise and bufitle mnat bi> prohibited ; and few persona must he al- 
lowed at the itanie time in tho room. If the child require amuHf-menl, h9 
must be allowfil only such uiuxcitinf; divewioii* or liookx. pictures, and 
quid Kamcis cun afford. His ffuid sLould be nf a light, unstimulating kind, 
tnich ait thin broth, milk, liRlit puddinga, and jelly. His thirst may be 
assuaged at frequent intirrnlH, cnrc being taken, however, that only small 
quautiticti of lluid an; allowed uu cuch uccottioii. Too large quantitieti uf 
liquid dixtcnd Uie Miomacli. impair the dit^tluu. and help to pkximute 
diarrhu'a. This is a fsict of some moment in the treatment of iluteaaee 
where purging is a common ^mptom, as meaales and typhoid fever. It 
is advisable to make use of n small glass iHildiiit; a1)i)ut two ounces, for the 
child will 1)« uanallv Ba1isfie<1 if allowed to drain thiti to the bottom. As 
tho patient grov.'K weaker and required more decided support, he may 1>e 
given pounded underiloiie mutton, strong beef-essence, yolks of pgg, and. 
if stimoLuita are rajuired, the bnuidy>aud-«gg mixtureof the British Plior- 

In coees whore deglutition is difficiilt or impoBaiblc, as in infantile tefa- 
iius or lh« iiamlyws which follows dii>VitIieri.i, and in alt casoN wliei-e tmia 
wilfulneKS or iueapocily !Ui ndequnte »vup]<ly of food is not token, it may 

ry to fe«J tlic vbiid through n tulje iiitmcluned into tlie tilximiirh. 
tioii is lieHt jieHormod by pamiing lui tilnsLio CAtJietor rhimif^li 
tie nose ond rlowii thn (^illf>t~ 'Urn intttniinont in mom roiivniiiRntly in- 
laced tliroug;h tbo uow Uuin lhrt>u;;li the moulb. hesa o]>po:iitioii is 
" hy this nietlux], and littlu or no irritatinn it|)pear)i I« be set ap in 
'tt* Daaal pAuagt'K. The tube ' pmpei-ljr oiled muKt be ilirected nlong the 
floor of tlie UM&l cnntj- txtto tfa« pharyux, »tid e*a bo then rondily pushed 
iloHH the fTuUet iiito the tttomiicb. If il cntcb n{r»iiiHt IJio top of the Inr- 
rnx, B. xpaaiiuHlic cuuf^b in vxt'itwj. Tbo iUKtrumt^nt luiiiit be ibou vvitb- 
timwn slightly iiO>l again pusbed foi-nards. Ther« is Little difficulty about 
the opcnitiiiii if the chiurs head be directed well backwards. By UiIh 
menui lii|uid totM\ oiu be adiuiniatcmd reealju-ly : nod iu oorlaiu diseases 
— especrially infmitile tetunus vrbora iiouruliin«nt in urgDully D»«dod and 
is indi»p«ri9Able to succesA in tbo tnatmeDt — feeding tJirougb tbe nose 
beeomeB » rnluabln addition to our resonicea 

If tbe powiT of HwnlIowin|;> bo uniDipaired, a simpler mftltml mny he 
3pted In such a caw it Ls only noo««ory to c*rry the food into the 
ice& If other meiuiH aro not nt haod, fluid nouriuhcient tniiy be pournl 
ly into the noRtril an tbe cliild lien in Inn rot The litguid at once 
mritates to the iMidk of the thront and i>i fm-allowed lui it ivooheR the 
tx. If prcfcrrctl, the fluid may be injected tbixiu^b n abort eamit- 
I tube pasitcd through the nose to the upper part of the jjidlet. In 
'AM. of tbeae caseo, however, the simple and iugEUious metliod devised by 
Ur. Scott fiattams,' and introduced by hiui into iLo EiiAt London Chil- 
dren's Uurj|>iltil. uiiiy be resorted to. Id the ciiHe of vrriikly or ct>llft])»ed 
intant« thif^ methud isinvaliuihle ; but children of nil iiges, if proetnitinl 
by illoees, con take nourishment more com'enientlv by Uus mennB than by 
any other. Tlie npivinituiH is of tbe simplest liiti<l, mid consists merely of 
u onlinary glu8« 8vriu(^e with apieee of Indin-nihlMT tubing, four inches 
^k*ng, sbpped over tbo uo/^le. The ttyriuge is tilled iu the ordiuiti^ way 
^ drawing up tluid through the tubing. The tube is then passed between 
chiKl'ft li])s townrda the Imdi of tlie tongue aix} tbe coatentfl of iha 
I vrrtnge aro slowly diftchnrged into the mouth. 

TIk-m' diU'crAot metliodfl of fooiiing nro nil uwfiiL The stoninch-tuhe 
jiasBed ihruut::)! tbe no»c should bo employed in all casea where deglutition 
^i» imniured. from wbitteTer cause — either from inflammaton,' conditions of 
' throat, from loss of exeitflbility of the pharynx owing to cereliral dis- 
'taat or nareotio poisoning, or from ixuiilysis, us uFlt^r iliphtberiiL The 
STfinge-femler just deseribed may be uned in cHHes of great weakne«ui and 
nnMtnitiou, and in nil eases where the power of swallowing is not iuter- 
brred with. 

The ijuention of tnlwri'nj t'-m)jcriilnrc when tbiH riucB to ft ddnj^eroiia 
PViglit i>i mi iiniurtaut onii. Childreu ofteu bear a high t«mp6rntLii-« wdl, 
and it is not always oa^ to say what degrt-e of hfat constitutoa hyperpjTCxiii 
ma ehild. liNTien the fevei* is due to a wptie eaime it is perhaps less well 
bonw than wheo it is tbe e<Hlseqnence nien^ly of a hx-al intlammation. In 
wej eoMB if the teiuporatiiro rise ahove IOC , or if the patient eeem to be 
difdrawod by a loss degree of heat, it is adrisable to sponge the surface of 
Ibe body with tepid water. If the fevej- be not reduneil by tiiia meana, ttiu 

'Ttic tiTRt inlif (o uie h a viilcMiUed tnitU-rnbtwr onlljeler nufflclcnllir »lllT nol Iw 
Ukk. \ S" i iq tlir mosi luefut Ate. 

'Mr. Ilaiuui'.i ]>ii)Hi( ou die Forced Fevitiug at Cltildnii, iu llm Laocvl of June 
19 «al Stf, IWll. In wbicU the Tarioiu tnntbixla vt feiritiu^ mc dncribvil, Is fall of In- 
iMM and iiMtrucUoo. 



cliiW shonltl ha plnppi! in n. Imth of the t^rnporature nf 75'. and bo kopt 
there uutil the pTKxui uiidcr>;oC8 n ecosiblo tlimiutition. Veuolly upouK'- 
ing the stirfocv uill rotlucc thu budiljr lii^iit bv M^vt-iiil defpntei^ to toe iiu- 
metUate rebi?( of Ihe patiimL. In canf-a of mlbmtnntori' diarrhixK, even in 
babies of a few- montoa old, the temperature often rises t** loy or 110*, 
aiid the cLild putaea uito a state of profound dtprcasiou. Ulicn tlus Imp- 
ji^UH (Ivslh in inovitabls aoless the pji'n>xiH ca.ii bo quickly redui^e)! ; und 
tejiid bathiog is o[t«ii BuecMsful in greittly retardiug if it do uot actnnUy 
Iproveut a fatfd issue to Ibe illoeas. 

In all foruis of fftrer tlie comfort of the patient is gjmMy promoted by 
tlio uxo of two eotfl — ouo for the dny, Uio otbor for tli« ninlit. In aaonot 
poricArditi^ trilh ropioui* cflViiiion, iu thn Ut«r p«nod of typhoid f«v«r, 
and in oth<?r iustancps wUcre the debility is estrcmo nr Uie action of the 
heart liainjiereil and feeble, tha change /roiii one «x)t U^ lli« other mugt be 
tnaile with every prr>cniitioii to ttpars the cliihl nil e|M>nlAUix>us ntOTMoeiit, 
and to keep bim iu a rccutubcnt po«turo. 

In thu treatment of diKeiiHC in iMx\y life the remitUes at our command 

I the same as are iisefiil for siinilar oonditionn iu the adult. On account 

^.3irev«r, of tb6impit-w«iUciter\'Ou» system in the voud}; mibject external 

applicAtiuUH iu« of greati:r inipurtnnce iu cliildhoou tluo tliey becumo iu 

^Jiftttr ytarn Amou{reit the remwliett of the greateirt value 1«th(i funn a 

of no little iujportanoe. Aceonling to the temperature of the irater 

''employed the bath becomes a seilative, a htimulAiit, or a touic, as may be 

required ; and iii Uiem difirreut 8bn)ies is ofteu renorteil to with great ad- 

' 'vanlagp. The U8^fu]ii«m of t«'pid 1>athtng iu rcdueing f«v«r has already 

fu rofoiTe*! to. 

The tmnn hath (80" to 85'Fali,) is very usefd in casea of coavulfliona 
or great irritability of the uen,*oUH Rintem, shon-n by agitation, reatleasneea, 
or diHtiirbed aleejx It cnlma tbe excitement, nllnys spasm, pro- 
jteti thu ocliuu of tbc tjiiii, Hud iudooea 8lei?p> Uii aci-uuntuf itatlinpbo- 
retic eflWt wami bathing ia of great sennce in cases of Bright'atliseaiie. In 
infants the wami Itathhas a sensible influence in promoting the action of ths 
■bowels, luiil iu fas«t4 of couatipation is often n vulunble addition to purgn- 
'five niedicinei*. The child ahould renmiu from ten to tweuty miuulea in 
the warui water. 

The hoi txtfh (95° to 100** Fall.) ia of great value as a stimulatit where 
tliere iH sudden and aevero prostration, snich u occurs in cases of profuse 
diarrhoiB, urgent romiUug, sliocki or other cause wliicJi induces a teuipomj 
depresaiou of the vital eneifiioe. When emplox'od in this way as a etimu- 
laut the child must not remain too long in the water or the stimulant effect 
win paaa off and be succeeded by depressioa For lui infant three^ and 
for an older rbild five niiniitett will be mifficient immersion. Tlie patient 
can thon bo rc-uioved, wiptd rapidly dr>', and Uid between hlmikota ^th a 
hot bottle to las fett. Tlii» bath may be matlc moro stimulating by tht* 
addition of mufitanl. Flour of mustard, in the proportion of one ounce 
kto each gallon of water, is mi]:ed up with a little warm water into a thin 
ate and pLicud in a piece of muslin. Tliia is 8quee»cd in tbo li»t water 
until the latter becomes 8trou;^ly niuHpiiied. So prepareil, the miiatanl 
Iwth is an important remedy iu cases of proHtraliou and ooUapee. The 
child aliould be held iu the batb until tbe arms of the attendant supporting 
jiini begin to tingle. 

The c(*/(f iluiiche is a tonic of the utmORt valua It must, buwovor, bo 
employed with discretion, for tJie patient if wcaklT seldom obtsins apropcr 
ctiou unless special precautious be taken. ll the child look blue or 




diilly oftcr Ihf bnfb, the Hh<K-k io tho ByHtom bus boon ioo riolcnt. 

a w«!kly cliild the cold doucbe slioulil alnaj's be gireii in tlie follow- 

g wMj : Ou rising frutu Im Ixtd Ihe child ia tbomughly ttbampnoed all 

T tlie bfKlj, using tit«iKly fnvtiouH c-xpedollv to the buck und loiii& 
itkiii bt'iu^,' tliu» stiiuulubxl and pn-pured to rcsint tlie shock of tliQ 
wnter, thu {j«tii>ut m nuide to tiit iu a taw inuheti of wiiter as but aa be 
[«!& oouTeikieutly bear it, and then immedifitely a pitcher of cold water (56° 
to 60") la emptietl nrer his abmildera. He is Lheu at. oucf twtnoved^ and 
mil rubbed with u rou^b towel to lund^t reiicUou. lu wiuter the bath 
•hould be [jiaced before the Gre, and every varo uhould bo taken to make 
tbft procen a rapid one. Tlw fihanipnning ^-iU ocriipy from ieo to fift««a 
minates, but the doni-bfl Hhoiild lie over in as many secondo. It is wfll to 
klknr th» chilil a. drink of mill: or a biwiiiit liofor« bc^^iuiiiii^' iht> jircM-CRa ; 
ud wlien dricil tbo cluld iimy return to liis bed for a abort time if tbougbb 
dewnble ; l»ut iiftrr one or two repetitiona of the bath this precaution will 
be unuec^sisary. So employe*!, the hnth niuxt lie wpiuiled purely as a 
thnrapeutic af^ent, and not 08 <i oloAnitiDg |iro>ocsfl. Tho l>ocly may lic wiutL«d 
in th« onlinary way at ni^bt Uforv tli« ■cOiild in put to bud. 

The cold doiidie ia of great sen-ice in all awea of weaknesii. wbetlter 
Ibk be due to acute or cUranic illness, and ia only iuadmiflBiblti if the ItuigB 
am oetively diseoaed or iiibrv in f«ver. it is eapeojally useful in case« of 
kiBg-eianding deiiuigvnivut and iu thu iicrofulotia caclteidn. nud may be 
racomm ended without bt^taliuu fur cliiltlren uf veir frigilu aupcaraaoe. 
In adtktion to its ionic efiect th« bath hfts another viuuable iinohty in that' 
itrtnogUienH tbe reaiatiDg power of th<> body U{;ainat changed of tempera- 
tnte. and le«Hentt the suscepCibiUty to cold. 

Tbe hot iknd mustard botba may be eocsidered in the liffbl of ooiuttor- 
initauta, which act throof:;fa the surface trenernlly and produtre a powirful 
■tjmulating tiffect upon tbe tla^ng ner\'outt Kynt^m. A similar menna of 
tmsiap the vital euergies oonaiala in tltc. fiiiploynieiit nf atimiilatiuff lini- 
lueotH. ThuH, iu Cifc«i;)tofHt4^1oi.-taKi8,eui-rt^'tit.' frictions with u Htruui^irritat- 
ins; application will oftc-n tnablo the child to expand tlie collapsed jwrtion 
[if hint;, and thua save liiui from immediate daiij^er. In many varietieK of 
li>CftJ iliiteaHe, eouuter-ii-htantfl are of extreme acrviee. Thnr may be used 
in tli« forui of blistent, mustard pouliiccM. nnd paiutin<; wiUi the tincture 
or liutmeut of iotliue. The kind of application tiest suited to eaeh pai'ticu- 
lar COM' will be described iu the proper place. It may be here »>tated, how- 
(Ter, that bliuteru oiust be uned Io cluldj'eu. <-^pe<uaUy to yoiuig infante, 
with grf«l <-aution ; and Bri'tonneau rei-oiuuirudi* tliat m every case a thin 
kjer of oiliil jm[K'r aluadd bo intcr|jrieod between the vcsinatjitg nurfcuw 
and thf Akin. A blister flpphed too long leads, as M. Archamlxuilt bna 
pointed out, to a aore equivalent to a bura of tbe thinl de^rrce, and liciUa 
wry slowly. Caution in tlie application of tli« iiim-n [xiwerful cotmter- 
tnitaiiti* ia enpecially to be <ilis4-r>'ed when the patient w verj' young, or is 
Ibo subjtMTt of dcfccttvi^ nutriliuu or of riu'onic dixeiuic. In such caecs ob- 
itioslc uiceratiun may be act aj), or gangtvne of the skin may be induo^tl. 
not to mention the esbauatitig efCeot upon a w«ikly patient of the |iniu 
ckimkI by tbe applicati>^n of the irritant, nud th« fffuitiou of a liighlv albu- 
omions fluitl. If diphtheria be vpidemic in tbe DL'i;;hbourhuotl, mistera 
•dwuld Derer be emplmed. aa the reaulting sore may become covered with 
the ilipbtberitic exiKluliou. For a rauug child a blister should bo of small 
me aod ought rpiickly to be removwi. I'uder twelie months of afi« ciui- 
Uwiiline applicattoBB sboukl rarely be rev>rted to. If used daring tlie 
Mcood year, the blister may remain iu contact with tiio dtiii for an hour 



wid ft half. For piwli luldiUotul yeor of life * furdx-r taU hour mny bo 
aii(l()d to titp length of time the application may be oiuploTotl ; bo tbnt for 
A i-hild of four years of age Uie blister may rranaui two houra and a half; 
for ft child of five, tlirof lioiin*. If v«a«atUMi liw not bpt^n produced vriini 
the irritant ia nmoy&X, a -n-arm brcod-und-watcr poulticw will mwq cauae 
it to iqipear. Tbe fluid can then be let out and cottou wadding B^plied. 
No otlicr dreatdnff uill be rcr]iiirecL 

Amonp^ hiltiTnal trmcx/Ku alcoholic Ktimulauts take a high place. Cbil-* 
I'dzen reduced by aovvre illnnn rPHpond wtll to thv action of nlcoLoL and a 
few timely doHes of thiH metlicine h»w ufteu. in a doubtful caw, turned 
tbo scale in ferour of recovery. So, also, weakly children with poor appe- 
iAic-v uiid ft^'ble digeetioiiB ofU;Q benefit t^rentlr by on alloinuu» of inDO 
witb tJiL'ir principal meal. 8tin)ulantB may be prescribed for theyoungMt 
infants, and in coses of great Heidcness may be repeated at frequent inter- 
vals. AVhou tbe pntieut is vprv >-uuDg and requirM enerKctic etimnUtion, 
asmnll quantity of vriiie or brandy often reputed h to be preferred to a 
lar^r quantity given at uioi-e distant intervals. Thf> rcnii'dy tuliould not 
be continued too long. It uiuat be reniembered that a stimulant ii not a 
tonic. It ia given for an immediate puqxwe. and abould be withdmim 
or gnuiUy reduood in quantity nhr>n tlie object liaa been attained. 

Touifis, auch aa qumine, ir»u, the mineral adds, and w^toble bitter 
are ahn of Rveat Talue in tbe treatmaot nf disease in the cluld. But 
i-equire to l>e given with judgment, and niutit mit be tulmimntered indis- ' 
criininBtf-lr benauRc tlii< pnticntR look weak and pale. A ff>obli<wlookinff, 
pallid child, in not always to be beni-liU^d by iron tuid other loQice. Saeh 
a condition i^t often dependent upon a rhrouic form of dy^wpria, tbe result 
of rfpeatc-d L-alanhs of the Btomsch.' In such oases a proper selection of 
food, and lUkalics given to diminthh tbe Mcretion of nmous and ncuLralijsc 
acidity, will hooii pn>ducc ii iiiurki-d iiupruvrtiieut in coaea wbci'e Ionics 
have been given without good reriult. Il to only vrbi>n local derangement 
has been remedied that the tonic becomes naefuL The aame retaariia 
apply to cod-livvr oil This riduablc remt-^Iy is inappropriate so long aa 
any dif^estive deruugement remiiins uucomvl^d. nlieu tli» alimeotaiy 
canal has l>een brought into a tiealtby Btflte, tbe oil is of euormona serrioe, 
and may \)e given in suitable dosce to the youngest infanta. It must be 
reniemWred. however, that the power of digesting Cats in early life is not 
great Under twelve mouths of nge ten drom wQl bo a KiiAirienI quantity 
to be given <m each occasion ; and if any oil i« uotioed uudigceted in the 
•tools, even this small quantity must Iw reduced. 

In c«»eK where, although nourishinent is urgently reijuired, oil cannot 
l>e digcHted, the remedy may be rubbpd into the skin. The external appli- 
cation of oil is of service in idl caaea of chronic weaLucsif and wasting. It 
is useful not only oa a nieans of introducing nourishment, but alw> as an 
aguut in promoting the action of the Hkin, wtiieh in mout fonuu of chronic 
'derangenent is apt to become inactive and diy. The application should 
be matlr at night Any nil in useful for tbe puqiotte. and it is not indis- 
penfutble that coddiver oil 1* employed. Tlw oil should be wmmed and 
then applied to the whole body with a piMM of fine apongie. At the same 
time if there is any special weakntMs in the back or elaewbere, vi^rous 
[Aiofion with the oil may be iise<l to tbe part it ia dexired to strei^tben. 
Afterwards tbe child abould bo put to bed in a llannoJ night-drej«. 

In the txhninistiiitiou of Jruyn to young mibjecto, wo must n-meitiber 
tliat the da»- is not iilniiys fo be calculated aectnding to the age of the 
child, but that children have a curiouH toleranoe lor some remedies and aa 

omoiu a snscepitbility to others. Opimn, it is well Icnown, Hbould Im 
givra vitli caution. Tli« ntoiecly iu, however, of extreme value, and if car« 
he tAk«u to be^n vritix only a smiiil quiiulilj', and to poettpone a second 
(low uDtil ihe efiect of the limt hiui hwn UHcertuiiiviI. uo ill efEbctn can pos- 
nbly be prutluced In' the nurvotii.-. Tliufi. for h cltild of twelve montliK old 
Kifrering from purj^g, if one di-op of laudanum lius not produced drowsi- 
D«ae, A second may iw- ^veti in h)\ uoiit»'tiiue; and ilie remedy niU bv nel| 
borne three times a tUy. 

Belladonnit enu bo takra by most children in targe quantities. Somo- 
tini«s the characteristio rasli ih produced by a email dose, but a much 
hr^ier quantity wHll be requirpd to dilate the pupil, and a further coutdd- 
■nd>lfi iocreaKO before via can pmduoe di^iiMa of tlio throuL or other 
phynolofpcal offect of the dni;;. It in oft«il nwwnuey to posh the dose »o 
KB to protlu<?o diUtation of tlie pupil Many ausea of tioL-tumn] inconti- 
nence of urine Hhoir no sign of yielding uintil some fn,inptoniH nro pro- 
dUMsd indicating that the H>-i(tem in reHponding to the action of Ibc remedy. 
A child of tvrelvi! luontlu old vt ill usuiUly lako lifttjcu, twenty, or more dropB 
of thiu linctiirv of bL-lkdouiin three timus a day : and often vrc can piish the 
do!<« nt Uiis age far beyond tliia limit. 

Beaidee bdladouna children l>ear well quioine, digitalia, aracnir, lobelia. 
nail many other remedies. Mercurx rarely Halivates n child, but luui often 
a powerftil sflect iu dfiterioratiu^ the iptality of the blood. A child ia 
offudty l«ft ex<^«)^T(?l^ jwile at the end of a iroiiree of this dni^. 

On account of the fi*equency of digeBtive (hsturlMUicea and the tendency 
la acidity in eai'ly life, alkalifta form n very vnhiable claitH of remedies. A. 
dose of bicarlKinsto of soda or potaAh noiitiiUiseH aridity, cheoka hy{)er- 
Mcrttioa of macus, and if t?ivt.'U nith a fi'w di-opH of vpiritii of chloroform 
and an aromatic, stops fenncntntiou. dispels Hutus. and reduces apaHro. In 
all varieties of <lyKpe|uiia in the cliild, and iu many forma of looseneflti of 
the bowels, thia combination ia of the utmost value. 

One word luny be said with rvfi-rvure to tht^ ubuMO of aperient raedi> 
ctnea which is Kt> common iu the nursery. DeUcnte children have often 
died from the eftiwta of a dnwtie purge, and many a case of typhoid fever 
has received a fatal impulse by lliiti meaua. Au aperient ia the common 
domestic rcmwly — the i-omi'tire to li* s'liiiiiiiitti^'red at once i^tuu the 
slightest appearance of iliuesit : ami |ji-cM-ribiij<; chemists invariably rucom- 
nuDd it as an antidote for every ill But constipation is oul^' one of many 
cames of malaise, and to irritate the bownls unnecessarily with a strong 
pugative powder may do aerioua injury to a weakly child. 

part 1, 




UuHiJB (rubeola or morbili) in onv of Uic commoneiit inioctiouH feiYini to 
wlncb duldreii are lial>I« ; and Tew pemoitK iirrive at adult yvim witltout 
hftving fluffered from an attAck. It affecte {-liildr«u of all a;^>i, aud is tax 
from uoootuiuou iii iiifaut^. Soattereil casee of measles mar be found 
almoiit aX uiiy tim» iu lia-^e tovoa. but at oertAin periods of we yeur the 
eomplatnt becomes (-pidemio. These epidemics tai^ curiously in M-vcrily 
sDd u Uie predoBUBBUw of twirticularsyniptomei. One may be (ii>^nlii»d by 
a hitfb perceotage of mortality'. Jn niiotJier vomiting may lie n promiuent 
and dLStreniDg feature. In a tliird tlie catairliid p)i<«noin»na may bo 
onanutUy sUobt ; or AKain, they iiuiy he sicven* out of all ppoportioii to tlio 
brteOBity of tue raah. V^lieu fatul, mi-mdcH is no ^ncrally thii)Uf,di its com- 
plicationa. It rarely kills by the tnteoHlty of tbe general diHeaii<>. Still, in 
■omo rmaeti we meet witti epidi^mica in wliicb tlie disnaM tends' to assume 
ao astbeiiic typ& Iu these the mortnlity ii lut^h. TUa fatal caaes ui-fs 
marked by early and extreme pruHtniUoii. TIk; patient sei<ms OTcrwhelmotI 
by the violencM! of thu attat^k. aud dies before any compUmtiou hns bad 
tone to manifest itself. As a rule, one attack protects o^nst a second, but 
wbere the diaeoae baa oroitrred two and even three tiiaes are not un- 


The contapous principle of mcawtles is apporentlv oommiiuicnted by 
aeaoB of the breath. It is said to be volatile, and to fie capable.' of adher- 
ing to clothing. Acronling to Meyer, it is easily renioveil, as Uie meiie 
airing of clothp^ in sufficient In diHinfoet them. Mci«ra. Bratdwood and 
Vuditr have o^miucd the expired air of mcaslea patients by making tbom 
breathe ihrouKh t^an tnbea coated in the interior with f^lyci:riiie. On 
uiminatioa afterwards with tbe mirroswjpe. the (•lycf'riiit' showed in L-very 
one nnmeroua sparkling eolourless bodies, some spherical, others mora 
elongatod witb abarpeued ends. They were most abiiudaut during tbe 
fint and a«coud d.tys of the oruptiuu. As a negative le)«t. tbe breath from 
Wdtby eltildren, aud cbildreu sufferiug from scarlatina (md typhus, was also 
aiam«d. but without aoy reeult 



The infection of measleB begicR nt the verv bej^inninj* of tho catarrtiftl 
Btn^-, und InstM fur Mime Xirae ufl-or the nutti ivin fnilixl. Dr. Squire ia of 
opiuiun tli»{. llini? wii>kM ouglit to i-lapse lx>fon- th» pstient cui be cod- 
aiilf^reit ttve fruiu ilU ctuuice uf uuiuiuimicaliut; t\u> (liseftse. 

Mfjrbul Jno/omy.— The post-mortem ftppe««iices in cases of <lea.lli from 
tilts cuiiiplftint are ttiose of the romplicatioD to which tti^ fotal tt-nniiiiitiuii 
i» nn-in^. Id cMes wbere the cldltl lui» AwA earijr from tbo 6«vpnl,v of the 
dtseatte, little is found except that the blood » dArfc coloured, deficieut in 
Abriue, and cnagtihitcH imporft-ctly. Tbcro in aUo hypostatic coDgestioc of 
thC'' lungs Mid h^^riPinia of Ibo inucotw mcnibnine)) and orgaiift |;<>iienil]v, 
mtb ettravBAation into their aubhitnun?. The tijilt^n and lymjihntio j;)nnds 
are often mroUcn. Uoclioiw of the skin mikdu ou Lhc toxtli day of the cni))- 
tiou wont 6xiumue>d by McHBn. Bruidwood oud VncrhtT. There woi; nnellin^ 
of the (Mrium, and thickenin;; of the rett> Sbdpiphii fn»m grest proiifpnitjoii 
of ccUn which extended aloiiK the batr nnU 6weat-<Uii.-t8 into tbo gUnUft. 
HutrlUin;;. i'i^iluurli.-:». ttpbt'ividaL tuid vlunt^lt-d bodies, siuiilor to thosa 
(biM>over(>d in tbv hn.'utb, w<>rv foimd tu tbe jwrtion uf tlie true akin lying 
next to the ret«, in tbe luugH, and m the Uver. In nil tliMe BituatioiiB toos 
bodieit weie mi^ed with oUier boilieH, spindle-tiLaped, atAff-abaped, and 
rauoe-shaped. Thoy apptuvred to l)o albuminoid in cbai-act«r. 

S'jmptoHK — Tho tncitbaliou period of nicnxks ia ten or twelve di^a. 
The tM>mplaint tbon benns with tbe ri^ns of catiirrb. Tbe patient ia 
tbnugbt to have a cold; Xw tmeexes, cqujcIik, and his eyca look w«t«ry and 
rC!t). With tJiin therf> in f«v«r ; often headache ; the apjietile is poor; and 
the ehild gODcnUly foela ill an<l ia languid. Tlw eatan^ial symptom* in- 
crcaae ; the nose mny hlru I ; there in souio Konnvsa of throat ; nnd tba 
patient ia often hunrse. and i>oiiipl.'UQs of sureiieiw in the cbeat. If the 
fever ia high, tbe child may wiuidor at night and be very reetlesa. Some- 
tiniea tini attack ia uabered in by a oonvulBiTe SO, and ooodaiQiially the 
ooDTuIsioiiB recur later on, eitber Ix-fore the nudi ban nppenred or after> 
varda The akin is generally moiht. altboii<j|b tbe teinjiemturo riBeeto 102° 
or 103% or even higher. In a case whi^h came under mv own notice at 
this stage, a boy waa aeiy-ed with diarrbrea on July ItHh. His temperature 
on that evening was 10:2°. Tho next iiiomiDg it waH 103'', but tlie bowela 
acted fire tim«« in the course of the day, and in the f^vening it had fallen to 
101.4*^. Hia pulse at tliat time was 160, and bis respixntioiiB were 49. On 
the evening nf the Till] tlie tempemhire wan 102', nnd on the morning of 
the IStti, when tlie roBh apponre«i, thn iiier«wry marked 103': piilse, 124 j 
roei>iralioQei, -iS. JUtbougb pyrcxin is tbe rule daring the pre-emptive staffe, 
in exceptional cases* thf tcmpcrsturt; may btt iionual. 1 bare known tbia 
to l>e the cMse in two inMt»iice& In each of these young children Ui« 
boilily licat, both morning nn<l evening, for the four days before tbo appear> 
luiee of the raah was between '.W and OiP'' ; and when tbe civptiou Iwguu 
the temiM-nittire only [kkc tu 101°. Tlie ntah was tyjrical in character, 
and all tlie catarrbai symptoms wer« present* 

'Ilie digesti^'e organs are usually deranged, partly on account of tbe 
fever ; partly on account of the mucous membrane of tbe stomarb synipa- 
thi7.iii!; wiUi tbe general demngoraeiit. Thn tongue is tbiekly forred ; 
Uiere is often vomiting ; and the bowels may bo relaxed. 

Tlie cboracteristir erupiion appears as n rule on the fourth day, having 
been prer^mletl by three clear days of catarrh and fever. In rare coneH it ig 
seen on ttie third day ; or, again, it may bo delayed until tlie Sfth, or i^ven 
lon;:cr ; but these arc e:[ecption& llierc ix in-ldom aoy appreciubb^ Hitb- 
Hideuec of the fever on tbe HppcunuiL'C of Ibc ntsh Indeed, the opjnsito 


tunuilly the rose. BotJi tho fcTcr and the calAirhuI symptoms ettai lo 
'1)e iateutiifipd when tJiR rash cotneH oiiC ; iukI if ctiarrmica have not- been 
prcMVit lM>fom, tttft bowolfl f^^onemlly brtuimn looae. 

The cruptiuo U lint wcii iLbout the ubiu. Ui« tcinplcii, and the fore* 
head, as slightly elerutcd spotti of il yeUuwiith roil colour, wbirii diwi{ipeitr 
under preasiue. Small at ttrot, they boou reach one and a lialf or lwi> 
Ubm in dtamet«r, and have irre^'iilar edges. Frou the fac« the nwil] ooon 
sprettds to the trunk luii) limbs, and iu twcuty-fuur houni in tt^aeraHy 
ftMid to OOTer the whule Murfuco of lht> botly and 6xtrt>milii«. Ar it 
apreads, Uie borders of neigbbounuij npotH unitf so aato form cresctntic 
patcbeH. Between theae the akin in of iiormid colour, uiileas the ofupliou 
w very probiae; in which case, as we often see on llio fitcf. thv jutictiun nf 
tiw elosely set spota inay produce a umforto blutih over u (xtnidderable 
extent of tiurfnce. 

Ah the muh hecnmai more noniplebelj developed, itft colour grows of a 
deeper ted ; and if the skiu be very moixt, raKielot witli an inflaoicd houo 
may ho soon Kattorcd over tho aurfaoc. A cliikl with the cniption fully 
oat and tho catarrhal qnnpbcHUB vrtJl marked, prcxenta a Ter<i- chartictor- 
iatio appearance. Uin fame m aomewhat awnll<!n, bo that the foatut^es ojipenr 
thick and coarae. A didl ref) fluitli occupicH eoj'b cheek ; and the forehead, 
monthf and chin ore itpeoklcd ovur vritb tho cni»cfnti<; patt^ihea, llio eyeit 
■TD red : Uie cydidx oongoMted ; and the up|M.T lip in eiicuriatt-d hv ihe 
CDpimu) duw of thin niu^iua from the noHe. Often cruMtti of dried blood 
■re seen about the nostrils, for epistuxiH is a very common s;>'uiptom. The 
nah reouuDH at ttu heii;hl for nlioiit twenty -fr>nr or for1y-ci<;lit hours, and 
than begins to fade. The colour cbungi*)* ii^iu U> u yellowi)«b roti, luid in 
a day or tvo has diaapp&nreil. leaving nothing on tho akin but a faint red- 
dish Btain, which may laxt for a few daya longer before the ncftmal colour 
of the integnuent is completely restorwL 

There are varietieH iu tlie rash. Souiotimes tho spots wliou tti«y Bret 
aroear are hard, acattci-od, and promtnenL These ai-o the caoes which are 
onEO mintokcn for varioljL SometimeH the eruption does not completely 
diaqipcar noder preHRorc, and we then oft,fln find Little pnintn of extrava- 
■itioD from mpture of small capillnries in the akin. ThU ooruni in cases 
wberu Ubcre is gnut bypencmiit of the cutimcous timue. It iu of no had 
iii(;ai7. A further degree of the same phenomencm ia HometiuieH seen in 
which the eniptiou [frowg darker and itjlrker until it has acquired a deep 
puiple tint. This is also the consequence oE ruptui-e of distended catane- 
oat eapillaries. 8uch a raab does not diaappear with pressure, and r^ 
ntioB Tisible for a much luuf^er time thun an urdiuary eruption, fading very 

The lever and catarrh remain at their ht^ii^lit until tlie rash Ijegina to 
bde. The Kovcrity of the eatairlml HyniptoiUH T»ric» very much in difTer- 
ent epidemies and with diffi^r^nt pntients. Sompiimes all tbo mucous 
mcanbnuies seem to eufler : the thmtvt ia sore : the eyen mo iofliuncd ; 
tiasn h deafiiewt from cIosurB of tJie Eustachian tube, and the inflammation 
mj eren uprGnd to the middle ear ; vomiting may lie dintrvtviin;;, and 
pl^ijig scvvni ; a mild liu:>-Uintui may become iut<niaified and Im' iwcom- 
pKuisd by tiiNuim (Htridulami hu-yngitiMy. All theao symptomH arv unually 
(;raatly reliered when the nruption liegins to disappear : and if tlien* ha i 
00 eomplicatioQ sufficiently serious to maintain tho pjTesia, the tempenv 
tare falla al once to ueuirly ita iiatuml Il-vl-1, uud the ptditc lotted much of 
its bvfjaeDoy. 

Hm dis^ipearanoe of the rash is followed by a fine desquainatioo of 



tho utin. Th* pei^linp rfiffprs nnifli from tho BhMdinp of flip utin whidl 
iit »uob u mu'kotl Hjriuptom ui HOjirlnLiiiii. TIr' upitbt-iiuiu fiiUti iu lui« bmn- 
like sqoIm which are often almuMt invuibW to the nakutl nye. ao that tltin 
Btage not unfrequently naaaes quite uuiiotip(>d by the atteudauta 

III iin uiR-oiiii>hcat«u case of auiasle« the chest s^plotaa arc lutuidlr 
mild. Thu (.-ougli lb at tint hard and hackinfr. aod during the entjttive 
period is often paroxvKuiul, with a kiud barking character. Aftei- tlw 
eruptioD has begun to bde, the coti^h becomes looser and lesH frequ<'iit ; 
and if proiwrcare l)« taken to nvoid rhillH, it won cnancn to be beard. Tbe 
phrfticid tdipis slx)ut tho cheat are those of imlnioniu-v catarrh. One cou- 
sequence of the irritation in tho lun;^ ttot iin bj- 1 be eAtnrrh is neldota 
i^beDDt, especiallj in scrofulous cfaildrcii. IhiH is eabngBineDt of tlie 
"bronchial glands If there he much throat affection, there mi^ be a «uii- 
btr swelling of the glands at the nngle of the lower jaw and at tliG sidett of 
the iictik. 

The urine during^ the fever is liigU colored, with abuiidant urates. It 
may oonlain a tnice of iUbtimeu. 

In »onio epiinmioR casea are seen which present all the ehnraetera of 
tho ei)nii>buDt with tbe oiifi esceptiou tliat tho ntsb in iiUhi)!. These are 
no duubt cTut^H of irref^ular meawee. Cases have l^een mImi ileacribed in 
whieh the rash in present, but tlie cntArrhol symptoms are alweut Imorfoitt 
sia« oaton-ho). It ia very qucBtiouable if these latter are daaeed rightly 
utuler the bead of meaMlee. 

Then is a form of tuejwles whioh in diHtin^ixlied by i^reat uroKtratioo. 
Bore the compWut tuMu]u«« fi-om the first aii airtlieuia type, xbe pulae ia 
small, feeble, and rery freouBDt ; tht rrHpiratiomt iire nuiiil ; the toogne 
18 dry, brown, and lliirkly furred : the t*mpenitiu'e of the body in high, 
although tlie exti-eiuilifA fenl raid to tho toudi ; and tho child is duU and 
Rei-uui tdupisliud. ^Vbcu the rush coiueH out, it in Liuperfbctly developed 
and of a dark rud or riolet hue. The xkiu is thickly xpottad with p^ 
tec]iiffi. Boon the pulae l>ei'4meB su nipid tliiit it cau only be eounled 
with diflicultr; the niUHcles become tremulww ; there is mattering de- 
lirium, and tiie pntient dies coraatnae r>r eonviilsed. These catwK, fortu- 
na1«ly ver^' mro. idiuost inrarinbly prove fatal. Tliey are generally aeeoui- 
panied by hemorrhages from tho muootis membmnes as well as into tbe 
' skill. Epitftaxw ih often ohutinate ; hiematuria may occur ; and after death 
vltymoses may be found iu rarioiifl iiitemiil ort^nna. 
In a healthy child iiu ordinary uttaek of nieattleH ia n mild dimnler with 
tittle severity of tbe general imtiptoms. Tho shorpneaB of the- lUnoes 
appears to be detenuined to Norae extent by the oonstitutioual tendencies 
of the patient. Quo of ttie pathological conRetjuenceti of the speciiic ferer 
'tiaguio ftCtiT« eoDgeeiiOD of the mucoUM membmnca, we might expect 
bat B constitntional state in which therp is already a prL-dispoHition to 
lenngement of these membranes M-oidd determine more nerioua symp- 
Ftoma than are found in easca where there exinta no eiich predigpoRition. 
Childreti who Htarl in Ufc wcifrbttnl with a scrofulous (liatlieus ore t^cuvr- 
ally liad Hubject« for meaMlex. It is iu patients that catarrhnl Hvmp- 
toniM sHstuue aueh prominence, and that ophthalmia, otitis, and the other 
troubles referred to above are eo liable to be met with- Even iu the 
Idest coac^ a certain dejiression follows the subsdenre of tbe fever 
tcvopemture sinks to a subuomud level, and tbe pulao is fvry alow 
ttnd intermittent 

Of all the eruptive ferera meaalea is. next to typhoid fever, the one 
liable to return. Many diildreu hare it a wcnud tune, often after 


onlT a short intoxul : and in ttonio comh llie Ronond attnck mnr oocur at so 
eariy n period after tb« Gret ott to coiistitutv a Iroo rcli^MM. CaBM ax« : 
with from tjiuc to time in vvliicli a chili] sickens with mmale^ 
thnmch a more or le«* (M-vyre iittark, recovers, and after a brief interral 
eosvalesccQRe aickcns with it agiiin -taitl all this within n tuuntb. 

GompluratW'iK — The oompticatious which may tKnihr &Ji attack of 
aln trouldesome or tlannwrouft have b««D alreiul^ in pni-t r«f»rrc(l to. 
s nJe, thpy Jiro oxrt^'^'*r;iUon9 of onhuary or «itruar<:liu!U-y Dvmploiiis of" 
Uie complaiut, unJ aro •leternuucd either by the charavl«r of the cpid&mic, 
Iiy tlifi <:onfttitutiiinal pfMriiliaritieB of tJie jxitient. 

Convnhuon!* h&va lieen already inentinTiMl tm occaKJoitalljr nuirking the 
of tho oUsoaBo. Th« lit|R may be rapwted wvenil times ; bat 
limited to the fintt ilay or two of tho disorder. lUtboii^Hi lUormiiiK to 
the frienda are seldem dajigeroim Should tliey be rt-pciited. however, 
during the eruptive Htage, they must bo r^oi'ded with wore anxiety, for 
th<-y may then pro\-e lataL 

BpiHUuis; a oummoo aninptom nod frenemlly ]iiBifn]ifi<aiit. miiy become 
profuse and exhausting. In iK>vere epiilemicH, where the tvpe of lb« dis- 
ease is a low one, this may be of serious moment In any case it raiurtj 
tend appreciably to protract tlie period of coiivnlescemie. 

Dinrrh'wt ix also, as a rule, a xyniptoin of Uttle i>unHei]U«uce ; but sotn^' 
times the iiiilil iDteetina] catarrh to wliirli it is owing may bo eonvortod 
into a real colitis. The Htoifls are then bloiuly and ghiiry. and there is colic 
with grrat teneHRius and pain in defecntinii. 

EATpigitis is a marked symptom in wme optdemics- There in geiier- 
•Jly a Mruiu amount of hoarvenMH early in tho diMUO from piu-tiHpntion 
of the Uiyngesl mucous membraae in the f^ncnd mtArrli. If tliiii t<C't 
worn tbe Totce beoomes husky and almost eitinct, the cou^h hoarse imd 
"CTonpy." and the breatliing noisy and oppresaed. Oreat alarm ia natu- 
tally excited by tliis conditiou of tlio puticnt, but the iluii^er is really 
■ligbL Wheu the nisli begins to fade, an tmpruvemKit is uotioed in the 
thnwt symptijuis ; aud they often diKap^ienr quite suddeuly wheu (he tem- 
perature fulls. It must not Ite ior);;i>ttvii that lar^itKitia with marked apasm 
may arise quite at the l)eginTiLi]g of the atbiek, and be out of all proportJoo 
to tbe ngna of gpnfnd catarrh. In sueh rases the existi>nc« of mnadea 
nay not be cren stixpocted untU the eruption cotnee out and diseloaes tha 
oafotrs of the disorder. 

tDpbtbalmia and otitis .ore less common aymptoms. When these occur, 
it is usually iu children of niarki^il sorofnlouR tendencies. Tbe tirst may 
(otm •& obiitiuate comphoition, aud tho second may Icitd to very serious 
aoBaequ«Dce« (Sec Otitis.) 

B]^«llsion of tbe bronchial calarrb to the smaller tubes is a very gravej 
amcleot It is oomuion iu babies and young children, and almost rnvruH- 
sblv pmvea fatal, for in early life eoUiipue of the lung is easily provoked, 
ntd onoe aatabliahed quickly terminates the illness. Tbe Srst indication 
tt dangar in these coses is oppression of the breatbing, which booomea 
VBtT rapid. There is liridity of the face, and the countenance is boftgard 
and distressed. With the !«t«tho!«cope we liear abundant line suhcropitant 
ttKuxhna oTer both sides of the chest. Whpn these syniptorasnre present, 
Twyactiro m«iwurM must be taken to avert a fatal issue to the com- 

In children who have passed the age of twelve months catarrhal pneu 
nonia is a more frc<)uont oompUoation than the preceding. If, in any 
oQ tho fodi&g of Uie nwh lb« tuuperatun uiulergoes httle diminu- 



tion, Tr« laftj exp«ct cAtAti-li&l inll*mmation of tiic lunf[s to be prdseni 
such k case the (JiilJ. intitead of beeoniinK better and more livelr u 
eruptiOD diaappeimi, ReemH to be Meaker ami leiu well thiui before. Hw 
fece, the sweliiiip tinvin^ BubRidecl, is tteen to lie piodicd aiul limf;^ikrd 
luokuig ; Lbt.-n: in ltvi(lit>- ubuut tbv Upit ; the imrea net in iuspuntioii, and 
tlw bieaUiiiig U ({uidc uud luburud. A tUenuumeter in the axilla marks 
about 1(U% seldom higher. The uetieut ui thirHty, but will tab* IHUe food. 
He abowa no interest m bis lojs, Init often lies pickiiit; at lii» lipa and 6u- 
gfrrs, iutUnerent to everjthiog but liia owu uiicomforlabltr M.usutioiiH. Kx- 
aminatioii of tiiv vhvut rovealH all tlie Ki^^ua of lurulc cularrluU piieumonia. 

Tlua oomplication may also comp on at an enrliop sta^'e, wbeu the erup* 
tioD is beginaing to ^pear. Tlic dcTeloptitent of the Tanh ia then retardeo. 
or th« azaDthem may eren rettuce<l« with ^'rwit aggrKvatioa of (lie geoeral 
spaptoms. Cstarrlift] ]>i]ouiiioiiia is fully 'Ui4cnlK-d in another part of th| 
Tolume, but it may bo mcntiouecl in lhii> place that catarrhal iodamouUic 
oiRiplicatin^ tuentilcH ofl^ii niiiH a AtibB<rute coitiBe, and pernsts long:; nf 
all signs of Uie inimar)- rouiploiat have disappeared. It niayend id doatb, 
in complete rvM>vtiry, or itiny become ft cbrouic k-«ion formiog one of the 
-mrietieH of pulmotiar}- pbtliisia 

SejMrftr. — The sequeliB of meaalefi are coniitituttKl in part by the , 
mentioned eomplicntiona, whinh, like ratarrbal jm^utiionia, may become 
chronic uud j^vo ri«e to double and anxiety. CUrouic l&ryugitia' and 
hrouchitix are cummoti i4«iueu(-eH. GnUirFied brotichial gliuids often r»* 
uuuii for a ouuoiderablo tiiuo relica of the (liueaiie which hua paased awajr.J 
Also, it may again be repeated that iit rliil<Lreu of scrofulous tendenciee anj 
attack of nieaslen may lit^lit up the ciirlif \iA. and f^ye rise to any or all olf 
the tmiibli-H which nrc' chnrfivU>riHtic of that oonstitutionHl iilate. Exen 
children wlio tire free fi-om this iinfortiuiate predispontion may not escape 
unhurt from the attwk. A condition of the aystem is often li>ft which »»• 
peara to faToiir tlie oncurrence of sec-nnilan' diaease ; and who«ping-<'oiigii, 
croup, f^nj^ne of Hip mouth and vidva niayoecitr at HUvh a »bnrt int^rral 
after the attuck tiist they couuot but bo looked upon ta direct suqucln: of 
the ilhieait. 

Ai.'uU> tubereulosis requires apecdal mention aa on undoubted and fatal 
oonaequenee of meaales. Meneiefl, indeed, is followed by true tubercoUr 
disease with 8uch frci)uency that in every cwae where we are called to a 
child who has boeu left weak aud fevertHti after a recent attack of the ex- 
anthamatoua duurder, we tnay cxpeol him to be the subject either ut 
catarrhal pneumonia or of acute tuberculoeia. 

^1017110111 H. — Defore the ataee of eruption meaBlrH ia not euK;v~ to detectbi 
Aiwii'<!rc colli in the child Im often accompanied by fever, nnd thero isi 
DoUiiui; in the oalarrhitl ^ymptoma of nietwil^'H which can be ooiuidwed 
peculiar to that couiplmnt. If sucb symptoms (K*our ut a time when we 
know an epiiieraic to be ratrinC- the probiibiUlieM are no doubt Btroogly in 
favour of an attAck of tliia disonlcr : but iti tbe op|)OHile ease, if we oannot 
tutrortaiu that tbo child hits been exposed to coutoi.'ion. it i» witte to wait 
before expr»HaiD(; an opinion, titill. we sUoukl never fortC^t in any case of 
hi;{h temperature in a child with si(^B of general catarrh, that these an 

' In All cHc4 of hokneaees left ftfter smhIm Uio vuckI eurtU abodtd, if ponlbte, bt 
(n*i>fcted <ri(li the larTtittowc-jiv. Tli« Kup[Ki«ed l«rjng{tM will W •oaiii>liiue» foona U> 
W moUjr MuraiiMor Ihc iuryixx, duo IO)(<.'ii<!ral dcVililv, combincil uith H-takn«i» cF llw 
wldunlar mmtrUn, wbkti fail lo apprnximU* tho cordi, TbU Incal oiMitinti may bo 
pneeal ■MMtt^lt lliu *lgnii of gpn«ral anvmU ara aol pronoancod. In «i«h casM we 
■bonld waick ibe eliild aiudootty tor any aymptoou ItLdtoitjre ot tuberaokauL 


(he eariir Mymjitonis of ineastes ; juul we Bboulil iuquire iw to tbo oxutonco 
of ibe (lise^LM- in the aeigbboarh<KxI. 

The preiM^tice of Uie catfurtuJ plieuomona will onitblu us to exclude 
Muintiim kHouIiI lh« enmbiiiMtiuu of sore throAt am] liii;li teiui>emture bavo 
led US to suepoct the uiiaet of that iliiionler. If lnr\'D>;^tui with stridor aikI 
Rpnain he au earlv sTmptom, tbe petaisteiice of higb fever nit«r tbe fspim- 
motlic attack in at ait f ml ^vill suggmt tlint these monifeDtatimifl may be 
>^ptoDi.itic of some Intent febrile dinonler, and we itliaJl remeinber that 
meulee iit sniuetimee twhered in b; lArtniEteal troablea. 

When the rash uppeare we shjill be lesB liable to fall into eiror. The 
flreacentip. itlightir eievBt4>d pntcbeH ^tb the nkin betwren tbem of fl 
hoiilthv tint, eotnbinod with ror^'zn aiul {"nuj;)!, are verj eliiiractcri>Jtio. If 
tliB eniptioD come out first tm biirilittli iMobitoil piipules, nuiUl-pos ma; be 
MUpected. aod indeed tliis is a mistake wbi<.Hi in often made. But the 
papules hare not tbe bard abotty feeUng peculiiu* to tbe Tai-ioloun erup* 
tiou ; tb^re is no bislorv of imin iu the bnck ; and vomitinj^, if it have oe- 
^1, 18 nmcli leas severe tluui the Tomiltn^' of tlie pi-i-eni])tiire period of 
gall-pox. MoreOTer, iu variola tbe teiuperature falbi notably ou the nj>- 
ic« of tlie nub ; while in measlefl, if any change occur at all in the 
(erer, it is in thn oii[]osit« direction ; and the cntarrbnl ayniptoms become 
aggmvated. Doubt in only pennLsgilile at the rery be^^ning of tbe erup- 
tion Htace ; for on the eecoud day tbe nutb of aniall-pox h^ eompletdy 
diaoged its chnrocler on the bSx of the patient, tbo papulea having become 
ooDverted into vpHicJea. 

Tlie rash of nweola may bcnr n nlosa Tesmiblnnce to that of measleR, 
bnt in the former complaint thtrt in no oatniTh, and tlie tempcratrnv is 
oonual oroulv tili}:;btly ck-viit4.-d. Bt-twecu i-pidt^miic roecolft (or rijtbfln) 
mewil«>« the difliculty of diHtinf^isbing i» uflen very great. Tbis sub- 
is referred to in the chapter treating of the former disorder ^see 
1 3(1). I have also knt»vii tbe early sinoa on the altin of au acute ^en- 
ema to present the i^'lonett j>oii8iblc' resemblance to measles. Biii 
ilbeui HhouM never be judgeil uf Ly tbe rush alone. In eivry cose 
we ebould search for coufirmator;' sj'mpftoma, and inqoire as to the tem- 
pentare ami tlie initiator^' phenomena of the illness. In raeoHlee vre ex- 
amiDe the eyes for injeetion, tbo throat for reduess, and auk almut cough, 
bo a nwneea; and catarrhal STt^ptome generally. If tJieso are completely ab< 
aoat, and die lemperature be beloiv 100°, it ia very unlikely tliat the d^tuto 
b mipwdea, however typicnl tbe raah may appear. 

Tbo etiuns left on the «kin as tbe rubcoiotis eruption dies away bavo 
beea compared to Ibe mottling of eypbilitie roseola, but the bifttor>* and 
cnurae of tbe illneai aare eo different iu the two casch that besitatiou la im- 

Profpio^A — ^The percentage of mortality in nveades is small. Still, it 
ii much higher in mme epidemics than it is in others ; ami, therefore, in 
catiinatiog the cthauces of a ]xitient'a recovery wn must take into account 
ih» charaoter at the opidenii(>. Anoiher consideration in tbe previona 
■lal* of health, espeoiaUy the constitutional tcndcaeies of the child. 
IJalMB the esse be one of maligniuit memdes. or tbe cbil<l bare boon pre- 
liottalv ID & atate of great wtmknesfl, Uiere i-t evert- hope of preserving 
life inordinary care be exerciMed in nursing tbo patient tlirougb bin ill- 
beta. Bat it is lers eoay to avi^rt injury- b> Ibe iR-alth (rorti Uie tlangerone 
Mqaeln of tbe ditieiu«. In iii>ite of nil we i-au do, a i-bilil of strong Kcrof- 
alnofl predispoBitioii mtiy 1>e left greatly iJie wnnie for tbe attack -, mid if 
hmUnga be already tbe oent of caaeous cotutuUdatiou, it will be di^cult 



iii<lc<Kl to pi-event liifi phttufiic&l tendeucies from receiriag n diffluM^ 

lu cUildr(>ii uiiilc'r two or t)ir«» vrani of nqe brouchlUii iu a ouuiiuon 
ooniplicAtioD. Here the child's |»-eviooe hetdth is a point of very anni 
im^Ktrtaoo^ On« danger in theiKi caaen is the nrciirTetice nf tx>lUitt(e of 
th« l\ing, nud this in prediitpoaed to by the preHeocf* of ricketR. or br gao- 
«ntl \T«ftkn«fls of Um potioot If tlio ebUA Ik- th« fiiibjoct of iniu-li«(l nrK«te, 
and luHHichitis Buperrcne, Im cboiiccs of recowry aro itniidL Another 
dnnger in the tendeoiTy of the bronchial inflammation to tunreiul into l]ie 
finor bronriiiid tulwH niid iur-v<»dc1eK and gire riae to ratarrfial pnftumonia. 
Thv occurruiico of Ibis nocitlcut tfniUlv incrtaottt the (^vity of the case ; 
but if the L-hild be n he^iltbv Kuhjoct, luiil the opidciiiiu bo n mild nne, the 
chunopH are in favour of re«overr. for in mPiwlsH caUirrhjd pueunionia ifiulsi 
to nin n siibncutt cotu-se. If. buwever, the child be vreoidy, oj the case 
occur iu the iiuiImI of tui epideiuic of unusual sererity. we hhuuld speak 
T«ry ^ardedly uf his hopw of c«cape. 

'jyealmrnl.^la. the ootIt 8tii)*e of ui(«sles the treatment is tluit of & 
fle\-«r« cold on th« cheei The child imist be kept in bed, put upon a diet 
of milk and brotli wilJi dry toH»t, nnd take for medinine a aaline witli sonia 
unBtimitlRtiuK expectorants, While the couf^h \s hard uid the cdmt tight, 
the ettniiikting expectorants, such &» amnionia, lujuill, nad waega, sliould 
on no aooount bo nitwlc use of, as Utvy iticrraMi the ti;;btne«B of the dieat 
and Tnake necrption more difficriilt than Ijefore. If Tomiting be distreaidng, 
nn 4^iaf-tio mnr ha given to r«HflV(> the Htomadi of uiibealthT secretioav, 
Musturd, or Hul]>hutt; of copper (gr. i to gi-. ^ every ten iniiiuteK), w to bo 
profrrrcd. for tiji:* pur]KMev as ipecacuaiiha has a rery iiritotiut; cfTuct upon 
the bowelH of tuime children. If there be diurrbcBa. a BUiall doiv of caator- 
0)1 or of rhubarb luid eoda will be of service at tbe beginning of the attack ; 
hut the aperient h1iou1<1 nut be repented, for in measles the bowels atv rerj 
RUMwptible to Wiv nctioii uf purgativeit. If tJie diarrhtoa roiitinue, a niis> 
txu-e of aromatic chalk powder and rhubarb, five f^nuns of Pach, may be 
given to a chil<l Uiree jrars of age everr night for three ui(;htH ; or he maj 
take oxide of nnr witli glycprina (two graina three times a dar^ and either 
of tliPHC will iisoally antwt the purging. Still n modemte lotwwnpHR rIiouIU 
not ho interfered with. It i» bettor not to employ a^tringout remedius uu- 
IcHB Uie stools are very watery, and tbreaicn by their niunher to reduce 
the Ktticnt's Btrength. 

The general management of the oliild muHt be conducted according to 
the rult-H already Liid itowii fnf the numiu^ of febrile ootoplainta (flee Intro- 
duction). In uiHeti of tneniih'Tt npeciid rai'e ithould he taken to nvuid dniughta 
while iuauring free reutilution of tho rouni. A atroug light hiirin the 
reddened evea, ao care hhouhl be taken to keep the room iu a half light, 
without ruakuig it ai.'t«fdly dark. Due altention lunnt be paid to cjefuili- 
Q08S. It is not neceflaary in ctwea of mMtakw to kmm the child dirty. Tiie 
«kiQ shoidd be cleansed every morning • twing tepia water, and W-ing care- 
ful to wnBh and dry arptu-ately cncli pact of the body, so thai the whole 
Burfnee may not be exposc<l at one time. The patient mar be allovtwl to 
tnke Huid often, but he louat be prevented from diinking tATge qunntiliita 
at once. The best drink is pure filtered water, and if a small cup oi' ^laaa 
ho uaed, the cbild uiU 1m? antis&ed if allowed to drain it to the bottom. 

The condition of tlie tliroat uauidly re^uiivci httle treatmuiL A Blrin 
of Unl wnuig out of cold water may l>e «pphed cIokIv round Ibe neck, aud 
be oorerod with oiled tiilk and flannel. Tliis can lie re-wcttc<l as often a» 
Ib neoenory. The HOuie application is iimful if iittn be much inJlun< 


tiou of tli« U1711X ; aud if qw^m occut- vnih atri(3alouB liretiUiiug, tliu 
broat may )>e fomented (i;r iij)i>l/iti^ bvlow the cilia a 8poD£« <Upp«l in. 
water—hot, but nut hot (>iiuiit<li U> scsld. 

A. single oonvulston does not require treatment; but if the fita &ra 
repeated, the child kIiouIcI be placed for a tav miiiiit4!ti in a wann Imth and 
Ibes be returned to his b«ii A hot hath is useful if rapillary bronchitis 
or catarrbfd poenmonta twcur early, and int«rfor« witJ> Qie doveWpm^ut of 
Ifae rash. If they ocl-ut h&tcr during the suluddonco of the eruption, the 
ciiild*H back should be drr-cupped. or be covered with a largf poultice 
made of one part of tnUHtanl to live or tax parts of linttDod meal. Thin can 
be kept in po«itiou for ei^'ht or tvn hours, uud aftvrvriirds the froul of the 
ebwt nui \m> ])uulti(-cd in tlio niiuo wiiy In cum-s where the ilnnjicr is 
gnat, thp dry cups are to be preferred to the marc slowly acting poultice ; 
and 1 bflieve life may be oft«a eaved by the timely ai»e cf tliia eaei::geti9 

Btiniulanta are not required in ui-dinary citHt^ of mMislex, but wLcu the 
patiflot in of veakly habit of body or of distiui't w.-roftdou>; type, or when 
w in suffering from an onusually severe attack of the dLe«>aee. it may be 
Dcceiiiiary to support the streugtli by alcohol. The bramdy-find-f'gg mix* 
ture of the British PbfiitQocopceia is vary useful for tltis purpoxo, ami niny 
b« pTen in soch doaca as tbo child's ago and condition rc<|tur«. Ciuldntn 
— rren rery youoK children — who arc weakly or pnwtmtod by illuoaa ra- 
qxmd well to Htimulantx, and can take them in coUHiderable quantitiex with 
gical ad^untage. 1 Itave often oeen an infant of ei^ht or nine montlis of 
tfgB greatly beuctitcd by a l^aHiiooiLful of bmiidy-uii<I-i!^g niixtun; (,'ivcu 
Roy boor Of tbtit qunulity a third piirt in pure bnitidy. If without the 
ocrurrencc of any Beven> complication the pHtieut i^eeniK tu be getting into 
a typhoid state, with ilry tongue and amiiU rapid ptdse, stitnulants are 
tugentlT needed. Ahu>. the preeeuce of bronaiilin or poeuninnia will 
demand a re(H>ure6 to tlie same remedy, or the child uiny siuk and die 
witli fitartluiiz ttuddcnncM. 

Food most also be ^ven with care and judgment, taking poma not to 
oTcHnnd the stomach, but to proportion duly tiia noiirinhment. both in 
qoaatity and quality, to the age and Rtreiigth of tlie ciiild. In all ooHes of 
wwlawM the milk lihould hv diluted with half or a third part of bnrivy 
VBtoT, so aa to iuaurn a proper dinKiim of the curd. In addition, it mny 
he guimled by fift(?«?n or twenty di-ups of the liaccharuted tiolutiuu of lime 
to prevent its turning acid upon the atoinaeh. TUik must be Riven in 
amaU quaotitiffl at regular int«rva]HL titroii^ bt'ef-tea, or beef-etwence 
made in the bouM-, is also very useful wlian the strength is fnilini^. but it 
mmt bo given tu vary small doses at Boffieient intervals. Hroiidy can be 
addail if n«c««eiUT. 

When the roHli begina to fade and the temperature fallH, the child. If 
oil] enough, may take pounded meat, tho yolk of an egg lightly boiled, and 
a bttle light pudding. 

Tho chronic M;qu«liB must be treated accordinK to the rules luJd down 
in KOch cases, and the reader in referred to tlie cliapteni treating of these 
■ubjecto. It may only be added that quinine in invariably requireil at the 
md of an attack of measles; aud bracing sco-air is very beneficial in has- 
tening tbe return of health and Btrcu[;th. This is of especial impoiiance 
in the oaae of scrofnlous tiuldron, who will also require eod-livcr oil as 
■DOB *8 tbeir stomachs can beai* it. 


En']D£»lC ItOSEOLA. 

?>fniano roMoU, often cnlled rothcln or Gertnan weafllea, is a miltl jjtfM- 
ti<HU conipkiiit wbicL 1>vivr3 no clt^M- a rrMunblmioo to nieMles that it is in 
all'proba'biUtv frecjiientl;,- voufouiidt'il nilb it Tbe two dis ouM a are. liow- 
erer, not the suiue, for rbtlidlti does uul {)n)t4>ct a^niuHt nien&leH, nnd is 
itself oftdi 9oeu to occur iii n cluld vrbo has beuu latelj the subj&ol of that 
iliHonU'r The complniut la almost aln-ajs a wild one, and bas no cooipli- 
catioiu) Of KtHjiiolH'. 

fi^tnploma. — ThoBti^o of inmibation is eaid to Imrt a w«!k. Wien tho 
disease tiegins, the child is seen to be about mid to look poorij. lie in 
slightly feverisb and, if old enougb, mmpIainH of heiularhe. With this 
tlioro are tbo uinuil acoompaiiimenta of thirst and wont of appdito ; and 
Bomfltaiiwe a pain in tbo \x\ck hem tx^u compluncd of — violent in cbarttRtor 
like the hack-ache of small-pox. The jffe-eruptivo stage ofi«i lasts ouly a 
(en- bdurs, or, indeed, may ue e\VD absent. Porbaps ite average duration 
may be tak^n at twenty-four bourn. Tbe eruption then oomes out on the 
cbrcktt, and Hides of the uo»e, as dusky-i^-^d t^^btly C'lt-\At«tl ptipulf«, the 
colour uf wbieli ditnipjN'iini ou presHure. The wrist« and uiikleii are attacked 
slinost OS eoi'ly an the f(ice ; and from tbcne points the rasli quickly spreads 
to tbe Teht of the Itody and timba On Uio cbeeka Uie taafa is more 
papular ibnii eUewlicre. It diifcr» front thv eruption of nienslM in that 
the itpotii do not group tliemselves in cre8cetjti(; patubes ; but r«B»mblM it 
in th« tendency of tbe nwh to bocomo confluent in places. Thus a large 
patch of uniform redness is often w-en on the cheeks ; and Hometimen we 
iind tlie ttame (continence of nudi on the wrintH and foreanue^ the lega and 
tbe ankleii. Ilie eruption in nttendcd «-ith a (i^ood deal of irritation, and 
when it ttubsiilcM, is foUun-ed by u idi<;ht fine dcsquaination. 

The jfcncnil sj-mptoma during this stage are trifling. Tlie fever may 
persist during' the first day or two, but often sabeodes soon after the ap- 
]>earance of the nsh. llie conjunctivn may be injected, but there ia seldom 
«otyza ; and if cou^h be pn^.Ht-ut, it i» iuai^ificaut One almost constant 
^XDptom is sore tbront. This gt>ii»ndly cuuies on with tbe nab, and, on 
inspeetion, the hucea ore found to be the Beat of diflftised redness ; and 
the tonoils may he intlamed and HW<JleD. Tlie (orenesa suliaidpii in a day 
or two. but after a sliort interval in apt to return. Tlie secondaiy sore 
tbroal in « chnmetrrislic nyniptoin of rt>tbeln. It m-cura between the 
tbird and sercntb day — usually, nccording to Dr. Tonp;6-Sniilh, on the 
IbuTtL or fifth — and is accompanied by preat pain nnd much swelling. In 
the sererer eaacR the roice is altered, articulation and deglutition are di»- 
trcounj;, and there ia much aecretion of aticlcr inueua. Iho tempernturo at 
tluH time may reach 103° or 104°: tdill, crra when the throat (^inptouH are 
worat there is no prostration or even auy feeling of general iUnesa. Some- 
times the glands of the neck are enhirged and tender , and in some epi- 




lies the poid-o<!rvi<^ f^AivIs biive been noticed to bo gnoll^n. The 
'"axillarj, inf^uintU t^Ianda, etc., tnay be alao a8«ct«(i. The duratdou of the 
eniptiTe stiiRc is tlirco or four days. 

As ftttack of rutbRln is tht-n, a» a rule, a vorr iiifrifi^Uicaiit mattco*. Tho 
difficult in to distingiuBh it from moiwlcii, wbich it m muoh ly^omblM- The 
two chief points of ilL^tiuctioii are tlie shurtor period of the eruptivne stage 
in i^tlielit. aiid the non-ertsceiitie arraiigemeiit of tlie riudi. The milder 
chora^tcrof the catarrh will hardly netre m a distinj^uifibing mark, for 
toBicLiuHiit in meaales the coukIi and uozyxa caoae little meujivutiivuc-e to 
the {NUient Auotli«r point is tlie lower t«uipt*rature. Hoinetiiuea in rij- 
UkelD Ihera eeeais to be scoroely auy fever mt all ; and vrbeu preseiit, tlie 
pjmxia (fenerolly eubeides on the second day. In spite of these points of 
aoDtmst between the two coinplaiota, we niiurt often hesitate to espren8 a 
pomti v o opinion upon a pnrtjculu' case, TIip nbiwROd of auy indtMue of 
^wwr whon th* ertqition mmea out may aflord a nuB|>i<'ion tliiit ttie cme itt 
. one of tnio meofUcii, Imt we ciui neldom Kpeak witli cortninty upon tho 
trst day of the rtutfa. On tlie seeoiid or tliird day, however, if we hnd the 
Rymptomft still retain Uieir triHinj^ eharocler, and if the fev-er sub- 
''iddu before the msh him hasaa to fad«, w uuiy couolude the ouo to be 
one of rothdu. In iloubtful cjlhl-s the morG or U'sm {funeral glandulur tn- 
bvgeaieat, esiN>ri:illy the sweUing of tlie cervioU and mboc'eipital glsudfl, 
in a rerj ensjjtdous symptom ; and tlio oecurrcncc of s««oDdary sore throat 
witli no aotnol aeose of ulneivi m very tiu(*-;eativi^ of riithehi. 

The diaorder hu been i]«)i<Ti1>ed »» n luHd one. hut it in right to aay 
thai Bone nutfaoritim hold thnl it may aiumiue u niueh more Hcvore chanuv 
ler. Dr. Chwiille, from careful obaervation of two ejiidemies, whicll pre- 
srated all tlie oharairterH of nieiwles and ncmrred in Huerewflon in the 
Mme district witliin the same year, coiidudod that the soeond of these epi- 
demiee wa« TAth«ln nltlton>;h the symptoms were sororc, and the larrnf^eal 
pbeooBKnu «ti>ociuUy well marked. He founded this opinion ii]>on tlio 
iiiarter period of inonbation during tJie xec^itd epidemic, and iipou. tUo 
h«t that out of thirty <mwit in whinh ahanlutely trustwtJrthy histonea 
orald be obtoiueil. twenty-two had hjid nicrtuslits before, mid t«ii of theM 
■Oder his own immeiliiite obeornitiou within the year. Still, we niny re- 
Bflmber with re;^anl to this latter point that meases, although as a rule it 
protects the sobjei-t for the future against a similar attack, is perhaps of 
allUlfl oontoeious fevera the one iiKwt liable to rerur. A aerond or ereji 
atlack LD the nme iiidivithuil i^ far from unc-nnimnn, and anmstimnH 
between two each attfti^kH i« euriouHly abort. 
TVwImenr. — The patient raofit be ranlinod to one room while the fever 
and cmre most be taken that he is not overfed- No medicine in 



Souojir (ever (or iicnrlAtiun) in, like mtiades, oiw of tho oommotier in- 
fectious {even of childhood. It umuUly occurs m cpidemicii wbipli vnry 
prcatly in neTeritj'. One attaclE. in Uic Ur^ majority of cwtcs, protects 
againHt a aecnnd. ior it iti a ditcBaa which very i-ajvly occoni twic?e in tUe 
jBune person. A stcond »tt*clc may, howeT«V, occur. Some time ngo I 
saw a little ^'irL ii;,'<.il ituroD ycam, who bad a M^ikilicaut hbttoiy of fever 
foUowt-d l>y deHquiuiuiliou and dropini'. which had utuit^kod b^r when she 
vms in perfect heulth two years before. The child was a patient in the 
' Bast Loudon CLildrvn a Uoopttal, sufferiug from e:^u«ial aiuyloid diecsee 
dependent npou RpiuaL citnt-8 which had fullowbil th<^ illttess referred to. 
While she wah iii the hu«)ital the girl ngum i.-outni«t4!d Bi-arlatiua, and waa 
Bent away to the Ffvor Hoepital, where she died. 

Sometimes the difleaae nppeam in aii ahorlive form in perMna wbo are 
already protected by a preTioiut attoick. In eiery fpidemtc of Mariatina it 
ia coiiiiiion to tind »uwg of anoriialou»i eort! tlimat n^cnrrinf;; in protected 
persons exposed to the infection. Snch persons may vommuuiicate the 
perfect <U)ieiuie to othen* who are not protected. 

('a»itatlon,— The fcvt>r ik of a hitihly infcctioufi nature, and is readily 

oommoDicablo from one individuciL to ftuother. Sporadic rasee are some* 

tboM mot mth. but ihu illncHM •^eui-niJly ociciint iu epidemics. The tnfeo 

tioua principle in prut»bly tiut at all voLitile. for article!* of clotlting, dan- 

nel, etc., have been known to retain iheir poisonous properties for long 

periods of time. It ia a debated (|iic«tion whether the diaeaAe erer has a 

■A qiontanoous origin. Some authoritieM hold that it may be generated (Ai 

noDu by oeflspools and ill-ventilated drainti. DitToreut epidemica have dif-^ 

ferent de^ea of aererity ; but apart iium the speot&l (>!>« of fev«r proviu 

lent, the tntenaity of tlw diaease ia dependent more upon the con)<tita- 

tioQa] state an<l* sanitary sun<ouniUng8 of the i-ecipient than upon the 

J,4evonty of the diseaM in the pcnoD fiom wbom the infection ia conveyed. 

■ ScTofulouH children, and thnee who are ill cared for, or are ex|io9ed for 

louK periods to an impure atmoRphere, are likely to take the diseaae 


i)ui-io(C the first few days of the iUoMS the patient is len dangerons ns 
a HOtirco uf iiifcctiou than he afterwords hecoiucs. The time of deeqn&inA- 
tion is probiibly the period at which the complaint ia luost likely t» im car- 
ried away, for the particles of epithelium tiirown off mnat be luRhly con- 
tagious, and Uie piili<.'ut'M jiotrer of comiiiiuiicating the diaeaae does not 
until the pe«htig uf the skin ia at an eu(L 

Searlatiua iu seen less frCHpieutly than monales dunof; the first twolve 

mouths of life ; hut lietweeD tiie first and E>econd years the diaeow is • 

common one, and. according to tlie rcsearrhea of l>r. Murchiaon, 64 per 

,C«Dt of the cases cmwut before tho eomplotion of the filth year. After tbe 



ieotli year the ilineaae agnio Iwcooaes lees frequeuf, although it uiuy occur 
fltiriiiK nilulr. life or 8v«n iii oxiit^imo old age. 

Mcrb'ui AiuUtymt/, — Aftor <Iofttli fi-ota scarlatina ve tuuallj find en- 
dmoe of thi- sjiccial complications which liavfl detemiined the fatal iasiie. 
2l iuMition the blond ccagukteM imperfectly, as a rule, although paJ« 
fibriitoiiH (•lots mny be found in the riglit ventricle. 

The porta especially proue to auScr arc the KOKtro-ititc&tiaal mocous 
IDembtHiie ntul tltt- xliuidul^Lr si-atem. Iii fiitiil auoa ioAammatanr- sn-clU 
ing ia found in thn lyinphstic ^laads of tlie ueck ; also in Iho foUicIen at 
the Lose of the tongue, aud iu thos<' of Ibo phnrvnx. tonsils, aad latrnx. 
la the iiitctttiuu thu Hulitiu'v (^limdn unJ ihone of i't-ycr'n p:it<.-hfs iltu oticn 
enlarged, re-ldened, ajid 8oft«?iied, lliere maj- be also enULrgemeiit aiid 
BOftening of Iha HpWn, liver and pancreas. In all these oreana, amxirding 
tu I>r. Kleio, there ar« tbiuit^eii iu ihc Kinidl blooil-vctwela. A li^i-aline 
tlnckening is noticed iu Ui« nrterioles. with a ]m>UfoniUon uf the <.-«ll)i ot 
Ibe eodolheUiuu aiid uf the nuclei in the muscular cuat, iogetber with an 
Koinnulatioo of lympboid c«lb in the tiaauea around. In the ^tro- 
itDteatiiwl mucous uieml»«De there is hyperfenna of the aubepiihehal 
laytfn. nod pT«at prolifpration of culls whiidi distond and obt)trU(>t the 
gutiic tubulee. isomotiitiee casta of these tububs may bo do(«et«d in the 
aiaUei-s ejected from the stomach. 

Tti<> cutaiieouK affei'tioii in not a mera hyjieneniia. It is also an exudjw 
tioD into the roio- luiiooMiiui. The cclU in this aituation are prnliferuted 
and BWoUoo, and the Hw-uat-glonds mar be stuffed and diistcadcd by their 
increaaed cellular contents. 8eraiu eBiuionH with ntigrution of leucucytt^ 
nmjr aJao occur, llie lynipliatio f^andi, cape^inlly tiio>te of the neck, are 
•slugMl ; tbe lymphoid rcUu disitppi-iLr, and in places large giant oelU be- 
tome developed contaiuiu;; mauy uuck-l 

The kiiluey presenta the charactera of aoute Bright's diaeaao. The 
^ole orf*an ia congested, and important changes are noticed in the p^om- 
cntU, the small artcrifla, and the convoluted tubes. According to Dr. Klein, 
changes take place very early, ho Ibut iu the first week of Oie disease 
proliferatioii uf the nuclei in tbe Malpi^bian tufts uiid iu the muscular 
eoftl of the artexiee oou be tleteoted, as well an hyaline degeneration of th« 
intima. At the etuue time there is hyaline thifkeuiug of Uie iTaQs of the 
,31nlpi>^)itiiu CMiiUaries, and cloudy sivelliug of tbe epithehum in some uf 
'tbe i-ouvolutetl tubee. At a later sta^e the cloudiness and swelling of tite 
labal epithelium increaaea. and fat^ degeneration takea plaru ; itilillra- 
UOQ of lymphoid m^IU occura into tbo interBtititl tiasuo ni-ound the tubules ; 
and tho tubii^a iliemsalTefl are fiU4Kl with hyaline casts. 

In caiteH of utHimia tbe blood is nometinies found to contain au enoi> 
moua ffitcena of urea. In a case r(>[M)rteil by M. D'Enpine of Meuevn, in 
wtlieh veneaection naa eniplnyed, tlie bliKid wilm fouiul to contain 3.3 pnils 
of urea per thoUftfmd. or about twelve titucti the uoruial quautitr. Th& 
potash Hults. alao. were increased to three times tho nutiinJ proixtrtinn, 
and of Una two'thirds was contained in tlie senim, and not, as in healthy 
bkiod. in the red corpuscles. From the ezpcrimeuta of Feltz and Ilttti^r, 
•ad otfacTB, it uppuiu-H pi-ubnble that thu tiyniptoius of unemic |K>i»oiiinf; aro 
doe not to the retaiuoil urea, but to the escei« of potash salts in the blood. 

/iyrnpionts. — After ©xpoBor© to infection a period of incubation pre- 
oedeB the actual outbreak of the fever. This stage is of verj' variable 
dtnitaon. It tniiy last only twf -uty-four hours, or be prolonged to u week 
or nore. Probnbly six days may ho taken as the onlinary doratiou of this 



Different cases of scariatind varr bo mucli in severity and in Uie yio- 
Icnc'ir^ of npecinl !4\iiiptniiia that it will be mtirnnient to divide tlie tliaeaM 
into Iwo cliinf forniH : 'Die ooounoii tnikl farm nnd tiio nuUiffiuuit binn. 
Afterwards the conipUeatitnui and wquelir mil 1<« (te«cribed. 

In the romTnon/tfrm the invasion of Uh^ disenso ia abrupt. It IieginB 
witb a chill ; the rhild complains of sore throat, aoil gcnei-ally voiait«. 
Soin«1im«Mi thnro ore nervous trrmptotnK, mm) in «xceptiotin] mutos the 
discasn mar he introduced by a cnii«-uh<ion or a »1«t« rvecimminfr coma. 
The toDgiie is t^C'ucrallv fiim^l at, tlic 1>M*k, red at Ihi- tip and etl^-s : the 
nppetite is loMt. and there is Ihiist. Tb« skiu is hot, and the piilRe nwi. to 
190', 140''\ or eren hi^er. Tb« ntab nouietiniee appears within a few hours 
of llien«> farlv ttyniptonm : ocQUuonall,v it nt iloelf one of tlio ourlr pbe- 
Domena : and nj^aiti in rare vases it ma^r be dclayeil for three or four dari^ 
or. it is said, evon for a we«k. As a nile it ia noticed within twenty-four 
lioiirs of the iieginning of the diRea«e. The t«niperaturo risea progrm- 
»iv«h- through the invasion stage until tlie rasli niipeors. TIm pjrTS^ is 
HOT, liowcTi»r, dxcoflmre. In the caae of the hltlo ^id, bitfore iisr«rr*d to, 
who was taken with scarlatina whil« in Hm hospital, her teniperahu^ liad 
alim^-s been norinal, but one orening it^wna noticed to be 100.2°. Tbe 
nf*xt morning it was 101.2", and thft ebild vomited mvoral times. Toward 
thft e%-onint; tho rash App<-an>d. and the mercury rsaobcd 103*. In aDoth«r 
caso— a littlo Ikit ngcA ui^ht inontJis, who was teething — tJi* tatnpcmttire 
for seTeral dnrs had l)*en 100°. One muniing it roue to lOi.S"; be 
voinite<1, and in a few hours the rash appeariKl. To the band, periu^c^ 
Uif B«kin gJTCs the impreasion of being hotter than it actual]; is, fcv UM 
heat is often ftccom|)«iii<'d by n |>enuliar ilirufss. whidi gives a burning 
character to it like that of [AiotmioMiii. Tested >\v tlio thermometer, the 
temperattire will be rarely found to e^eMd ll>5". 

With the ii|)|>«a;'au(w of the nvdi tlie inivewn stage tximee to an end 
and the eruvtnii' rtssije bfigins. Tli» rash finrt ajipeani aa scart«t jHiints, 
not oleTftt^d abor« th« mirhcA. llieM ars clotidy ftet, and their borders, 
which are paler than ihe centre, untie so as to prwluce, when fully deveU 
oped, tlie appearance of a uniform pint ground dotted Uiicklv orer with 
acai'lat points. The nuth raroly affects tho face to the nune degree that 
it do«B th« rest of the body, and diflcn in this re«pcot from the uruptioD 
of moaHlc& Usually the region about the mouth is oompanttivtJy fre«^ 
and oontrasta by its palenesA with the deep red tint of neighbouring parts. 
Tlie colour of tiie raah diaappeora on preaaure of the tinffer. When the 
eruption is conHuent. a» it is in a typiod caae. no int4»-i-euing healthy eldn 
can ))e sefaii. Often, however, the uruptioD is not coufluent The pimcta 
are then more or lees isolated, and mar be aeparated by spwwa in whieh 
Uk skin haa th« uoriual colour. The ros^ may be couHuent m some places 
not III others On the clieeks. neck, cheat, abdomen, and inner aspect ol 
tho arms and thighs, ooalwoenoe of the neighbouring jnioctn is usuall; 
complete. In other porta the spots may be more or less Molat«d. 8oid«- 
linieR the rruption ta everywhere discrete. Tho piinrta are then ttsnaUr 
larfi^r; and if at the same time tlio t«ni|)eraturo i» only (Jighlly flnvatM 
and the som throat insigniHoant, great doubt mar lie entertained as to tho 
natui-e of the disease ; especially as when tlius discrete the sputa ore o(t«n 
a little elevated. Theiie cases have been mistaken for meHides. 

Again, tho colour of the msh may rarr. It may In very pale, bo as to 
be only diBvorered by nircftd cxmuinatioa : or it may 1k» duakv and puiv 
ple. Often it is m<>i-c loak than smriet Somtlimcs it ia limited to certain 
parts of the body, such us the sides of tbe neck, the chest, or Abdotoan, 



oanDot bft detected upon tlic limlKi. It is usually said to begin about 
'Ihe mot and sddeR uf the ueck aud oa the cliest ; hut if lu), tlip«c [tarts 
pteeede llie rest of the body bv a very tdiort interval, luid thn null b»- 
comett j^nemL very quickly. It is at ila liei^ht ou lUv third or (ourtb d«y 
tW i]luea& Tliera m tlicii often u ^khI ilokl u/ irriutiou uf Lbu skis. 
Hom« HubeutiuiHOus iMittua '» [Jtv^out, wbic-li luakeit the liugers stiff 
elatnsy<lookiQg. The rasli runy 1>e aocoupanied by miliaria about iho 
utd cbeat; Uie Hkin l8 often i-ou)^'h from eulitrg<>inent of tlie sub- 
'•otaneouB papilbo (ciititi aiiiwriiiA} ; and ])e)«cliiiu are uut uufr«'<jueiDtt)' 
present TU«se Hinall liiciuorrhagio m[iou do not net^t-tMtuily indicate 
apedaJ sererity iu the attack, ijuiuclimra also Tesiclsd or even _ 
taay be noticed. When iht: eruptimi is at ita beigbt, a line drawu upon 
tb« rodd«DAd surfiMW by the tinger'iiAJl nuimiua tituble nit a wliito streak 
for about ft minutck This sign turn b«eii couaidcNd to be pathoguomc 
The Tuidi be({iiui to fade on or after the fifth day of tlii.- illutttsa, aud 
uxually fomplelsly dinajipeared by Uie t^iitli. 

buiinc tho eruptive stage tlie HyinptaniH of the invasioD period inetfaat^ 
iatcusity. Tim luu^^ud clcaiw aiid bttuuiuea deep red vttk swoUeo po- 
Bo IU lo pr«a6ut tliD wvll-kuowu HLmwb«rrii* appeturanoe. Tim cluld 
vefT tliirsty, but in Ilia uulder canvn liaK a fiui* up^iotitc. Voiuitiujf is 
aeldoEii r«peat«d &fter the dirstday ; but iu exoeptioiial cuaos thitt aymptoui 
IB an oboliuate and dintreKsiri); one, nrldinj: greatly tfi the gravity of tlift 
CBsa. If mvere. it uiny rodiicn the toiupai-atui'o. Tim soroiiotm of throat 
xxKuRy increaws dtiring tlm rruptnyt iilA^ ; auil i-xnmi nation of lhi»\ 
bocea ahovra a bright redne»i of the- soft iMiUt4\ uvuliu toiisilH, pillars ot 
the hnrea. and often of the buck of the pliartuK. fSoiuetiineK tlieite parts 
m abu> Rwollea from wdcitia, ho that the m'uin la broad and the t4Tiiails 
nntly ucot in the luiddle bue. Tlirrv i>» al^ iu uioirt oases excess of ton- 
■niitin secrctioQ, aud yellow pulpy uiatlvr uiny bu twoii collected at tluj 
moaths of the foUicuIiir reet-siii-A. ur e\eii cuatiug tbo surfuce iu » luiiform 
rtr. If the matter do uut eacape, it may form an ab^ceee iu the tonsil, 
in couiuion quinsy. Iu tho more severe cases the tongue lo&es its moist 
:« anil the niu(*ou8 iiiembnuie of the mouth, a»d thnjat geiier- 
\y, }oek» dry aud ahiniug. Uidous in the wornt oases, ulooration dws not 
oocur until tbo disenae i» Hubetding. UoinetimeB lit an early period the 
dbeafle is coinplit^Led witli ilii>hlhenn. If tlie tliront afTertion is wTerr, 
titers is mucli |tnm nml torulemem ui KWaltowing ; tJip voice is iiildbI in 
qoality ; atid the gl&ndi« of tbo neck Ii«coid« «niari;ed and tender. The 
inflammation may estcud fmm thL-m into the connoctivL- Ukiuu uiuuiul, and 
end ereutniilly in suppuration. In an ordinarj' oiae thu tlii-uut Lini)ruves 
as the eruption fadea ; but tlie tonsils and the lymphiitic glandu niay re- 
aain snkrifwi although uaialsaH. for some Lim« after the i^^ilummatiuu has 

The degree of pyresia as a rule ii; moderate. The tumpt:>rMtur(> iwldnni 
xiaM kbore 105", although m exceptioonL cases it niny reach a higher (-]<■- 
ion. UnlfAH it he inainttiiiit^l liv tije prenetire of a febrile complication, 
tera[>eratiux) tends to subKido when the rash Ix^ginK to fade; and a 
tb«n usually nocum, the bent of tho ho<ly boing normal for twcuty- 
Caarbocink Hltould tliis rrisin not occur, the pyrviia ninr bo prolonged 
for servtml days. Kven iu a mild uncomplirjiteil (-uHe t liave knoft-n the t«-m- 
pomture to remain eleii-arjHl two degreoH abore the normal level for twelve 
(bfT& As long SM Ihe fevi-r ouutiuueis the pulm} is ns frxiqui-ut as at thfl 
bsKtmiiog, and sLii-keua vrhm the temperature £alU. It oftvu n^clice 160, 
lad thsa frequeut-y in nut to be token as it sign of danger. So, 


lium may be prewut. luid if sligiit ainl tvcumiij; only at iiiuTit, ia ni>t «( 
serious import Tbe chili of teu complAiuit of betulAdie uid of aelting poia 
ft1>out tb« linibB. 

llie tirine in Mantr and higli coloured . It raay conteio exoem of bile jng- 
ment. «u<l tli^re U otten a Mxliment of UtbatCfi nr o( frw uric aojd, Ac- 
.oonling to Dr. Oee, tlw dilorideii are iient4i)>lj- rcduix^t in quantity, and the 
'' limplioric ririd uaiJergoM a d«c>dc<l reduction. Tbo ur«a is not cevca- 
Rnrilv increased. 

"tho ilfxfiiiamalive ulage begina a few dara after the rsah bas faded. 

J fxact period at vU^h it can "be tirst noticed is Tory variable. The 

t m^a of ]iGfIiii(r luiiy b« tte«ii while tlio akin 18 stilt tinlcd vith the re- 
mniiH of the priiptioii aiid before the jtm-sia has nibudetl : or it may be 
delayed for boiqi- ilayn or ereu w««k» uin-r tb« rash has cliiuippcared. It 
ittBually occura early *in proportion to the intonfuly of the eruption, and if 
'tniliaria has b««n preMut, is often rjirly and [)i-ofuM?. In tht* ^i^ht^r cbrck 
it lusy be long d«ln\'(>d. niid Dr. Fnt>o f.ti\U-n that after a mild nttuclc ht* baa 
koovra deequiunation to he postponed for tivo «rO«ke. The eptthcUum ut 
first looks dry and may be finely wrinkle<I. Tlieu, on tjie oerl, iiput-r 
part of the chest, and front of the ahouldera, the akin begins to EaU in lue 
bran-like ecnlos. Over thom parts wh«re the mticlo i* thin and deli- 
cate the de«<]uantatioD is rerr mie. Where thi- altiit ia tliicker the parti- 
rlex thrown off are larger, and In same pLof ch. auch aa the hopdB and f«t-t. 
lat^ areaa of e]>itbehum may be east off unbroken. On close iiiRjx^lioi] 
of the peeling mtrfcu^o the culiclo n-ill bo 8<'«n to be raised in the form ol 
an empty Todclc Tlic crown of tliia tk-vntiou falls, leanng ii uiiimtc cirrip, 
which gradually oxtends itaelf, until its rircumferenoe meets otlier cireli^s 
idemng in tlie Mime way. If the orown of the veade does not bre<ak ott, 

separation of tlie epithfliuiii may go on, at the peripbeiy until, by the 
ic« of neighbouring ceatrea of deequamatioa. Urge tnicta of slun 

throvu ofi. 

The proceEH mav he orer in ton days or a fortnight, or mnT be pro- 
longed for weeks. )t often lingent long about tlic fingera ana toM. A 
Mcondaiy dpttqunntation in even Raid in occur in mme casec, and tbo peol- 
ing imdafcocs a epociM of relapne. Until the laBt flake of epithelinm hu 
been cast off the patient cnnnot be eoid to he completely treo from in- 

In this stage the pnlae ia at fir«t often slower than naturuJ, and. may 
intermit. The teuipemture, also, after IheceaeatioD of the pyrexia, rematna 
Buhnomial fur wnnedayti. 

In ma/iyiKint ntir/afinii the aeverity nf tho diaaaM is ^owii eith(.'r by 
violence of nervous pheuoineiui which prore rapadly Eatal ; or 1>y (he eiuly 
appearanoe and int^ii^ity of the throat affection, wntch cuuaee death in the 
Brat or seoMid weok of thr- ilhiesK. 

In the first form the diReatte from tlio beginning may tihnw tho utmoat 
violenee. The vomiting is ro|>cnte(1 ami distn^'^ug ; the child is agitated 
nnd delirioug or convulsed ; the t«.-iiipemtarc riaoaio 107" or lOS" ; the 
breathing is quick and allallow ; the pul»e ia rapid. After some honra or 
days, at-ourding to the violence of the symptdus, the patient tanks into a 
ntupeAed condition with ha'ggnnl. dusky fact-, cold cxtmnituis, a feeble, 
rapid pulse, and a moist skin. Ho vomits frequently or may be violently 
purged, and dies comatose or in convnlBions. In tlie worst cases the pi- 
ticnt Nccnui litcmlly overwhelmed by the intensity of the ferer ixiimm. and 
dies before the nwh iippr-nr^ or the aoro throat ban afwiitoed anyt;]>^-i:i1 
prominonoe. Thus, a child may be found a few hours aft^r his thvtutliii-k 



apaed or uQOon8ciou% romitiDg inoessuitlj-, aud passiug frequent, thin, 
■naUsry sloola. The tbroat preseoita a dasky redueae ; tiie piiLw u vcnr 
npiit (U»l feeble; anij tbe tiiennoineter iu Ihe rectuui murkx 102" or lOtt . 
In a few hount ttie temperature fimm to 105' or 10U°.; <x>nTulsions come 
on, tad tbe child dioti. In other cn»e» bo liiigon louder, aud may «ppciar to 
nllyfor n thn«i but tJie dflpreetuou contiaueii^ tUo etupor relunuv aud 
death ooonrs Inr tbct eud of tbe week. 

Wbt'Q the oiaease nssurnds a maligiuuit foi-m ft-oia exaggeration of tbe 

tlinNil (UTectioD, tbe oounte of tbe disease for tbe first few i\&ys preaenta 

aotlting ubuormnl : btit on the fiftti or sixth dtiy tlie fnuf'e.s hci^oine exces- 

sivelv teatler, and d(>;:fIutittoii in very difficult nud piiinfnl. Tb& lyiii{ibiitio 

^UMB at tbe angle of tbe jaw and the conneetivc tieeue around them m 

infinnied and swollen. On examination of tlie throat the miicouti mei 

Inaoo L8 flcnn to be of n <lofp red or ilark pvirplo colour, nud {lat^'bes of 

why gray osndntinn innMftr ar* dotted over the surface of the soft palate, 

arala, and tousila. In tbo had aiacn ulcenition tokee place in tlieae Hpotflt 

^^ail. sprading. caiues wide destniction of tiiwue. Tbe face in often livit 

^Eid liaggnrd ; tbe puke U quick, fi>nble, and fl)itt«nn|;; ; there nit) aor ~ 

^Bft tlw teetb and lipei ; the ton^iiv is <lr>- nnd bruwu ; the futor of tbt.- 

|p axtoeme ; and an offeoaive piirulunt dischurtce vscupos from the uoge. 

^ihe aame time the nwlc bw^IIs and fweU brawny to the touch ; the akin 

mdta away ip places ; and thin, purulent nuitter, with sbreda nnd lumps of 

dooglur ooonectire tissue, are discliArised tlirougli the opeuin;^ The 

tloughmg of the subcnianeoua tissue of llie uock iH often Hceompanied 

bjr other tterioua Hymnlonm. Hismorrhagu may take phu-e froro the large 

Bels ; oedema of the {{lottia mar occur ; tbe ]»tiG&t may fall into a ty> 

Did state or die from pymmin^ In one way or anotlier sudi caee» w 

Rrmiiiatn fatally. 

>Vb«n the throat affection nesiinica a mnli^ant form tbe prostration ia 
seniUy uarkc-d, iiud tliu pitiout lien iu a drowsy utato. although be aeenig 
iteUigent enough wlien roused, Tbe temperature is not exceiwirely elova^f 
B.l, HoMom rising ithove 1113" ; but tbe pulse U very r.i]iiil and feebla It ' 
imp rrtaat to know thiit the sw«lliu(; of tlie vervii.-al gbiiidtt iu not always 
pruptjrtiou to the severity of the throat con^^citioii. aud fiiniiitbi'ii no 
^tuul upfjti wliich to establlKli a pruguo^ Deep-eeated sloughing aud 
t«t bi«iaoiTbrige may oc«ur in cases where tbe external glands are only 
ioilerately enlarged. If tbe throat aflTectioD ia severe fi-om tlie first, tllo 
•ppearanre of the i-a-ih ni^y l>e delayed for sereral days ; and it may uomaj 
fHit in a patchy iiii(ttii"r, hiding mo«t marked in parts where the skin ifl 
■Uliliilillj thin and delicate, as tn the foUla of tbe arm-pitu aud groina. 
Sometimefl we find the aboro two fonuH of malignant fever cnmhineii 
JO uervoua irnnptonis ore in cxt^exR, and there is also serioiia ulvcntlion of 
be fauoL-s and dvalruvtiou of titrauv. OouvubsionB occmTin;^ from any 
luao during the cruplirc period are of vcrr W-'riouH import, and geueruUy 
td fatally whether the throat srmptoma are mild or severe. 
Cttmplieationa and S^qiieUtt. ^Tho intercurront diaordcro which are liable 
daring or after mi attack of soarlct fever mar he lookfxl upon as 
itiuiM or 8<^pi«he, acconliug ax to wbethur or not tb«< disease i> ' 
ilarsd at an end when the temperature retumn to n uoi'mal leveL , 
IIO0I of them ariJje duriug the eecontl week of tbe illness although somfr ' 
nay oooor earlier. Tliey will be described in tlie order of their oceur> 


Daring lliejfrvrf w---^- tbe fever miiy bo complicated by lUphtherio, diai'- 
,iul ocoTZib Tbe ulcemtive Uiroat affection, which by many 



lOocHideced as a oomplicatiou, baa b«en<ioi*cril»da8aphueof Uie: 
it fomi of the fer«r. 

Dipblberia tnu^- be an earl^r ooiupltoatkm of smriet fmcr, and mny spread 
.to the ooae and hujju. It ofteo comee oo dari&g tbe fint v«ek of the 
icaa, but tnay occur later au<l at a time wben Uie ]>ali(Mit u aupposed to 
i rapuUr Bjiproacbing oonraleaoenoe. It geoeraJlv pruvw fatal. 
CaiT7Ji of B mild cfaanwtar Dccuning in the ootirw nf the first week ta 
^BotuHyuiptomof nufavoorable omen ; but if itpcrBtHtintotbeaoooadirecli 
' . becumea more amoua. Id nudi canan tlie mtarrli lua^- Bpread aloiig 

tube into Uio tjmpanutD luul net up otitis. It lo anr oaae th«" 
diactiarge baouiuvs fetid, it au^^gcata the preaetice of dipbtAeria. 
Diurrfacm i» Homettinea ao early compljcatioii. It utaudly ceaaes 
a tlay nr two, bat nuiy prove ao aevcgv aa to outkuigir tlw Life of tli« patient] 
to Henoch it ia pNOOdtd by mvlliD^ Of U» Pierian and Bolit 
adft SumetinivH an the niah (adea the diarrfacn. which had at &r^' 
ppeariMl uf littlu im|iartanoe, pamefi into a true entent-colilia. Hio tt'iu- 
ttUFA whii-li btit) fidlen riaea a^in ; thero in nauws and often ronutiti^ ; 
llic IkiIIt tK KwoUvli tuii.\ perliaiffi tnulur : and thu Rbtl<l <:oniubuna much 
of abdomiiiitl pnin. Hie lougue. *\ry and hot, in furred on the darmm. 
rail at tlie tip and edges. The bowels are kioee. and the stooU rontain 
Djucb fooO partiallT digested, mixed up with mucua and aoDctiiaea with 
blood. The ctiild looka ezoeHsively ill Hn<I rapidly loaea &es^ Ue may 
die from the acuta attack, or the coiuplicaljou may pass iuto a dtronio 

In tlip fectmd icect brnnrhitis and poeonionia, rheumatism, and eeroua 
tnfUnimatioiia may be Hoen. 

BroDehitts and puenmonia, which are pommon in moaalcs, are oompara- 
tirely nuro oompUciitions of acorlatiuo. It is much more frequent to find , 
.fnflaiiiuuitiuiiH of tJiR MTouii memhr-inca. et^iedallv of tlie pleura anil pet 
audium ; uiui thcMo are often lUMtwiated with fiyinptams indistinguislutbU^I 
troto ihtmo of rhcuoiiitiina. 

of tba third, nncl is often met with hs a complioatiou or MN^iiel o( the tevur. 
Whether the diaeaao la to be looked upon lu a true rheumatism quire 
indepeixlout of the aciu^titioa, or at no arthiitis resulting from septicaatuia, , 
or aa a ftuther manifoHtation of the Kcarlet fever poifKm which may faateai 
iil»»n the jointa aa it may fiisten upon the kidneys or the thront, in atiU &1 
iiialU-r of iliNTiiMfiicta. Tku ilieunmtic attack certainly foUowa t3ie ordinaiv 
'ijiinu- of thnt. disMuw ; it frt'iin«iilly alTeclH the serous membnuiea in ana 
nrriiiii'l Oil* hniirt : luid tbe jomt iutlummiitiou aubeidoi^ aa a rale, aftf-r a. 
ditv or two, nJtliiiii^'h iu asrt-ptiuuid cases it may end in nppQlAtiOD. Tliiti, 
in»v. Iiijwovar. fjctnir in cnm-s where tJiere in no sunpictoa of scarlet fever. 
('ImlocFmlitiH IM SH i-ummou us ]i«rii.*Artliti«. and heart diiiease in tlie t'liili' 
nU»-u iljMDrt fiyjio nn iittaoW of wArUtina. Plctiri«y mid periearditiB hohio-J 
timt-M citmi' on io tbe third week inntead of the Mx^uud, and may ovcur iai 
(•am wlii>r<> joint pcuna are not cniupUined of. They may then ho a symp- 
iJiiii of |lriulit'»diK<R»p : b»^p^ri<rarditiB(^omthisanu8e is not v^ common 
iti tbi) clilld on a eei|U(1 of HfArlet fever. If plcuriqr occur the eCniaiou rcry 
niplrlly tMieoiii<<ii purulent 

In'tbe thint ifvvl- tlie patient ifl especially liable to kidney uii«chie(. 
At Uiia time, too, or aborU;r afterwarda, otitis may occur, and gangrene 
and ntMcvHMPH ttiay make Uieir amwiuiwoe. 

Tlio iirini> HlimiM be e!tnnnne<l daily throuKhout the Ubeaa for allmmen. 
TliU may l>o fuuml at any time (rom the aeeoud to the twenty^rst clayJ 





It iH, lioweTnr, in Uie coarsa of the thirtl week that it in e^iieciall? liable to 
be met witli. 

Albozainitria doos not bftnr any rolntion to srveritj of nttndt. It nuy 
be preaeot iu mild ciuteH antl abeoDt in uevcre oiiea hy ititolf it doea not 
inilif t-* serious reonl miiicbiot and if small in cpi&ntitf doea not affect the 

If tlio al'bunuxiurift i« due to luijlluaR more tlum a umple coDKeetiuu 
of tli« kidnRTH. which ia of lit<l« CAJujiequfLa;. tlu- urine kood idiows sif^uii 
of th*^ prrsejice of uepbritin. lU <iiiiiiitity in rediicetl : ibf colour 18 smokjT 
trom tb« presenoe of blood, or CTeti de<<p red if th^ hainorrhag*' ta co- 
jnouu ; boiling throws down a oopii^iis pi-et-ijjitAt« "t ulliuuieii ; and renal 
epitWium. bluod-dinkiK, mid casts, ^iiuiiilHr luid ('trithvliuj, are diaoovend 
by the microfMVUH'. At Ibv SAiatf tiiuc or uhdrtly aflerwartla tbe bM Ib 
pBl« or piifTy-tookin;: ; tlie eyelids are alifTiuid nwoUeii ; and more or ksa 
csdeiua i% uolical nlioiit the legs and aiiklea. 

Tlie bef^uiiinf* of tlta kidney conjpliciilion in g(>iicrally njinonncvd by 
wmitiDg, bea«Ucbe, low of at>petit«, a dry skin, a {lallid ooiu]>lt'xiou, an ir- 
regular pulne, and a riw in tliu truipi-mturo. Tbo tt'mjHinitun.- is not very 
high, iteldom exneading 101°; and tb« vomiting ia not often repented, al- 
tliougb sometimos it beoomoH a diiitre»dng Bjtnptom. The oHlemn VAiics 
in amount. Somctiict-K it ia bttlu more than ^uiliuuttK of tiiu akin. In other 
eases the BwelUng may be gcucrul luid ncvcre. no as complttcly to alter tbo 
natonl expresdun of thv face, and greiiUy distend tbe limbH nod lower 
port of tbe back. At the same time effuaion may take place into the se- 
ninti (siviticM, tb« huga, and eren the glotti». If thist! c (Tiinions ar**. rapid 
Bod cupiouM, ^rent liridity mid dytt^mota may enttiie, atid death may tiiko 
place with startJiuf; mpiiHty. The most violent nttiw-ks ofdvApnri-a may 
be induced by interstitial <cdem» of tb« lunga. Tbe pntiuut is foiind 
IplpilTC for breath, with n liaggard, livid fare. Hia eyen are islaring and 
aaoffWted, bia lijm Itliie, and hb* nnils pur|ile. His pulne in weak and 
r^nd and bi» hi-art'a actiun feeble and llutteriiit;. Ou uxamiuatiun of the 
cheat few phyidc^ aiipi* arts to bu <Us<.»vercd. The rhoncbi arc w-nuty and 
scKttered, for very Uttle fluid, if any, exudes into the air-pfUiKa^fee and al- 

In a oMTtaiu proportion of cases urvinio it>'roptoms may occur. Tbe 
cbibl if. perhaps, violently conxubed seveml timeH, and may bip»e iato a 
state of coma ; or he miky bo twined with beudat'he of a very (bstressitift 
diatacter. Fortuti;tt^'ly these Nymptoiua usually pass off under the influ- 
tooB of judiciotDt trf^lment. It ia exceptional for a child to die of scarlit- 
tJDoas Dephritbt. The ocnurrence of tlie reniil mmpliciktinn appears to bo 
depeadwit in a (tmiX Tacfamro ui>on tlie ebaractor of the epidemic ; for 
wlulc in aome it in a coniniun H^^-mptotu, i» otluira it is almost entirely ab- 
■etiL Tbe popular impression that it in always tbe eonseqiipiice of a ifbill 
baa been disproved over aiu! over a^'itiii. 'Diere in no doiiht that if albu- 
mlnotu uephritia be preaeut, n chill mny lut«t«u the oeciuTCuce of dropi«>- ; 
bat that Ml)4<ht vxpoiturc, such ns occura during c-onndexcenco from HLiirlet 
frrer, aui determine the ooourreuee of tbe uepbhtia is now very geuerully 

In the earlier stofce of tbe nephritis llie amount of urine is fUminiahed 
sod ita specific gmxity is raiited. AiU-r a time tbe secretbm becomes more 
nwioos sod at tbu mudo time its den>uty falls. Usually the pyrexia flu)>- 
■ueswbeu tbe ijutuitity of urino incroaAes. J>rop«y in not an iDYariable 
■jnptom. It may be completely abi^iit, althoujrfi the othpr phenomtma 

well marked. As a rule the ucphiitut is rapiLlly recovered from, and 

IS casLDva. 

rat imiN- 

dowB adtpoHl OD boffi^: fcr ■ laog tiae • certain 

I Batf be tnMSt, aad ■odar th* BJaiMeDiv the adiBKAt 

tncKUbctcHtodf tolKB, b «SD«pliaHl ca*M a ptROMMttt 

ta»j-beletL b otber saitewa^ aad Amh «]« pfOMifalT moM 

,ftiai>»i»agy«i|ifawt tfc>iiiia>cM«MlaeoMt»iaJbmmMd 
iadeed, «i0i tfe Mu M^iaB of a knr vcriAe anntr, maj prc- 
antaBthattanefaaofhaytk tta tht moiMkn of th* kSdner* is wA 
ujuijulitL, hmI iS^ «■■««, MkAMaMntlcAift wiifdeteXBUDe'sretiini 
af afl lh> aait* ^wftn— ntncfa h«re btea rlwuBml. 

DnipBjr vitlxiat a ttwiiuiutiri a is txammtlfy mvt triih. and tlifai not a 
■UB* aaimti ilican'. In aom* at Iheae cases aUmntniim bas been 
]vearati but baa OM^fienrci In owKn tbere baa been bo pnoedest 

OtoffiMg* iaa not utioa i M OD Wf J ic a Hc a oC aeariatma. Tb»dHobarg« 
ia oft«a doe to an inflanunatioB of tte cstena] meatos, and is tbea, if at- 
tended to qoicUjr, ci fittle cooa wp K M oe. In ma&T caara, bawefer, it ia a 
teautt of axtanakm of the catarrh from tbe piiamix or naMlrantim thnragfa 
the EaatauiiiaB tubo to tbe middle mt. It m Uwd a more anioos matter, 
for tbe trmpamira soon be<wtaes disteniled intb its pamlml owlcsita 
Bcstrurtioii of t}u> small boDca (4 ihe t}rmpaDnm usukUt folknn and tbe 
pofl bursrting thrtra^ tb« tjmpame tnonfarane eampes hy tbe external 
oaubL Tbe moet eerKnu conseqneneee ma; an«e fn.>«D tbis cotupUeatioii, 
an will be deaaib«l eWwbrre (see Otitix. and it» conw^uciirrs). 

Abaoe^ea tony occur in the Becond or tlunl ire«k, or Uiwanls tbe close 
of tbe stage of denoaBiatioti. The«e collections of |n» often delitj coo- 
Taleeoence. and if uusy occur in tbo neck mAr be tagim of eenous import. 
In tli(> ccrrical rcgirtn thvy are neau-lv ainnvs tLe nifult of internal iilcera* 
tioii. In eTcry case, therefore, a careful esamuiation of the throat fdioiild 
be made, and active meaeuree are required to prerent anr spreadiu;; of tlie 
destnetive pioc««B in tbe phaiyni. A not narommoD seat of abisccn at 
this iMriod is tbe Bubmucous tissue at tbe bad of the pbaiynx. Tlds 
Bubjoct is eb<ewbere ooustdered (eee Zl«tro>iiharm{!eol AbMMS). 

Gangrentr in \-ariou8 parte nuj occur. Cancrum oria occasionally ful- 
kiWB emriot f*vor ; iiud giuit»ryne of tlio vulva, the phaiyux. the nkin of tbe 
abdomen, and that over & euppumttn;; pUnd mAv also l>e met with. Some- 
timen, as mar b^lpen in the case of any ferer of a lovr l}-x>e wliicb OSUMB 
tHpiil reductaon of the str^igth, ftcArbitinn, if serere. is foll'm-ed hj- luemor* 
rluigic purpuni, inth bleeding from soveml miinms eurfaceB. Brtn death 
may emrae lut n conHeonenct of the Iosh of blooiL Nervoua aeqtieliB B)«y 
be alwj met with. Infantile spinal namljsia bas been knovm In occur ; and 
hemiplegia from plugging of the middle cerebral artery w ee«u in rare in* 

In «<Mttioa to the above complicntiotn, («nvlalina is sometimes oonfueed 
b,v tlie prewnceof other specific ferers. Diphllierin luw been already oicii- 
tioned. Besidee tliia disease, meeAles nnd mnall-poT have been sevendlv 
known to attack tbe ecariatinoii>i jmlienl, and run their couTMi ut the tcaue 
lime with it. Tjrptioid fever and acarlatiiia have been also met witli to- 

Ibere u a form of scarlatina nlucb boa been called latent. In tbis 
vorietr tbe i^ymptomn are mild and ill-lrfined, and tJie raah pale and im- 
perfectlr developrxl, or e\'pn quite absent Indeed, tbe nyiiiptoms gener- 
allj ore so httlo B«vore that the esistenoe of the fever is orten not suqwctod 

rEVER— 1 

aatn dfequiunnlion bc*nD)t- It in thcii rcmerabon-d thnt the Hiil>1 hml 
rompbined o/ a |wk8)diij^ Hon- throat, imd had aeetned langnid aud ln-ar-j for 
k da^ or two, but nothuifr mora Id tbeae mild caaea t)i« nftcr-4>oi)r8A of 
tbe Uloess is not ft3wa,T» in baniKfoy witli its be^nuiii)?. Indeed, in no 
nae of scarlatiDA. hovrbvur slight tEio early 8ymptoiiis iiinj iipjitor to be, 
can we venture positit'oly to prHlict a fHTounibl» course to tb« iUnesut. 

It wiis lon^ doubted if the fonu of 8«(trlatiD& which occurs aoiuatii 
after snrgi(-nl op(>r»Uoiiit wita i\ trae BcnrlAtJim. The caric»iu-t; usuidly of nn 
iooiret«Te tyi>e ».iid t)ie geiieml nymptonu trifling. Still, u more se^t're 
Innn of llie (lisease is oeeaaionally met witli. Tlio rush »pp(>arB n fevr davs 
two OT three in most caaos) after the operatitin, and iimy 1>e almost thi> o»l/ 
'(irmptom. There ia often, however, high fcTer. but the soreness of throat 
is insij^ilicnnt. Oi!ira»onnltj d<^uamution is abaant Tlio healing of 
th« wound is t^-ntlv retArdod by tJio comphcation. That the diaeaaa in 
rmllv ftciu'Utiuit in shown by the fsict tliat it protects the patient from th»i 
fevtT poison iu after-Ufa 

Dtttijnotig. — In a trpind case acarlet f atot is a difteiuce n-hinh con acareely 
miHlukeii. The initial TOinitinf^ aiid tmro tliruat, with ulenition of lom- 
klurv kod nipid pulxe. foUowt-d ou the xecoud day by a, unifonii pink 
. dottc<l thii^ldy over with HL^iirlet putit'tA, ia eufficieiitJy Gharactenstio. 
. srtunately, niauy cases are not typLca). Tlie sore tliroat may be scarcely 
perceptible; tJie nuJi may he pnli', <iiiicivUi, and partial ; lutd the teuipera«J 
tiure on the morniusi of Mio seennil diiy n»;iy bo little olovntod abovo the nor- 
mal leTt'l. A chiM with cbronid wdfirjjomontof the tonsils, who ia Biibject to 
•toacka of soro thniat, ih fouml to he feverish, to have Home pain in neghi- 
tttion, and to present n pale, ill-developed discrete i-ash limited to the neck, 
ehcol, ahdomrn, and liii^lisi. In auch a cane it in nllon'nble to feel aonio 
BaeatvuulY n.-* to tlio nature of tlie luliucnt- The appearance of tlto tLjxjat 
is. bowvvfr, hereof ituportnuce. TIk^ redneHS In iiol limited to tbc tuuails, 
bat cxttoida over the soft palate, uvuht, art^hea of the fnueca, and often 
Ui« bAelc of the pharynx. The redness is uniform, hut at its mari;rin on 
~ e soft palate some pnuctJfonn retbieas may bi- seen : or ilie redness may 

imncUfonu in ch&ntctvr on the noft palitto. nrtd iiuifunu elsewhere. Such-j 
^bioat, ncooinmnied by vomitiug, a hot akiti, a quick pidaa, uml a whita- 
^, tODgue, 18 very flnapiciong of scarlet fever. Some forms of erythema 
the raoh of scarlatina very closely ; and if there is a history of » 
tseeot unwonted indulgenco in diet, the tllne«s may be easily attributed to 
tlita eftuae. If such a raah be nccompaniod br a normal temperature, iwar- 
lattnn may be positively exehtded. But it is inipr>rfant to remember that 
tlw increase of bodily bent may be verj- morlemte, I have known tb6 
morning temperature on tlie seoond dny "to be only Dtt.ii , or one dcgreft 
•bore the norioal )e\x-). ulthtnigli the diHciMo vrat n truo m^iu-liLtiiia. which 
tftarwanla became better dt-veloped A pulse of 140, however mild the 
otfaor aymptoiua may be, should make us auBpet-t the existence of the fever 
•wy Btron^ly ; and m no caae whero llio temperature reaches \W' or over 
imald we -venture posilively to exclude tliediNease. An erythematous meh 
iiKldora so widely diffmed on is the eniutlon of scarlatina ; and in |inrticu- 
lar )• iMoalW ab«ent from tlie neek and limbs. It also aprendM \*erT irrogo- ' 
lariy. In all casaa of doubt we should iminiro about pnma and atifTneBS in* 
tba articnlntnons, niid exiimine the joints, especially tliose of the lla^^ent 
for sitnis of tiwellinp. Wo should also fcfl for enlmTjcd plands in the nook. 
O&tok tboao symptoms ore prvsont c^irly, when the 0^1)11011 i« M-r\ parti^ 
vaA tscmnplete. 

When the nisli is dork colored, discrete, and idightly elerattnl, it may 



be intiitalcaii for msfulM: but Uw nimenoe of meeziiig ami Wtmrmation,] 
atMl tiie proaniw of brif^t dkI injection of tho throat, with ait onusiuUlj 
niHtl piuw.-, tilioulil fmiiisli u suiBiacot dtHtiucttoa. 

Iti)mxiltt II1II.V 1>L' uiistiikt.-ii fur scarktina. biit tlie rose eruption occtm ia 

r Iwger spots, utd imlei'd niorf rcHGiubW meuRliw titan the iliaoase wti are 

eMisidferuif^ MorpoTi-r, in ro<*w>la there i« littJe or iin f*vw ; ito BncU- 

inK of till! juLuts ; aim! tlie rupidity ut tlie pulae i» oominl or only modemtcly 

!f curlnliaa niuv bo clottclr EdtDulat«<l br acne. Dr. Cbeadle bu datcribed 
Uiu i-juK-n uf two cl)U<lr«u in wUom iho akiD ituritig tlic liot staf^ nas corerod 
witli a briglit reA nub. TIjU tiniptioii. combiiuVl witli u <{iiiek |mlse and 
n liigU Luinporature, wah v<-n- Bug)^«tive of sirtirUtbia, ami uti^ht easily 
have been inUtakvu for it Ttte JistinguUbiug jwintd are referred to vIm.- 
whpre («po A^^ie), 

Suiut'tiDU'A in tb» mild ojiomiiloafl cwu* of tbe diMMo doiiqimmBUou 
tnar b(> long doloyed, and tbc nltsetic^' of peoliii)? mar bo bdd to e&clude 
[(KHU'liitiiui. In tfaAWOMM «« tav dixi-ct«d b,v Kir WiUijuu Juntter to examine 
Llbe Nkiii iiboiit Uk' nxiUi of Uit- fluirt'r-uails for si^ns of Hoaling', as it may 
[bo (bMiH»vt'i'(<il in tluK situutiou iih egirlr tut a w«ck or ten days from tbo 
toMHatiiiii of Utc illncm. 

Hcarli-l fvvt>r in liardly Uki-ly tn be coufooudcd with diphiberia, for Uie 

invaaion and K«ti*™l sjrtuptomn of lL« two diaeaaes are very diiTireiit. It 

is iu)])ort«ut, liowt'Ter, Qot to overlook the possible interciureuoe of dipb- 

Uivha an a c«mipLciitioD of tbe fever. If tbi» unfortniutte aocidt^ut happen 

OArljr, diiriug tbo fintt week, tberv is tisually an ol&nsive di^'Uarge from 

i tJui nodtrilH ; tb« vuioo oft«n bocomvs hoarse ; and Uiere are symptoms of 

^ivat dcprraaon. If it oocur at a later peiiod, when the patient aeenu 

njtpnmohiuii conTaleKecoe, the fever returns ; tbe tltroat becomea again 

. juunful ; the glands of tha neck enlarge aod are tender ; tbers is a dis- 

' dMiue frum tb* noet : and in most mbm tbe la^rsx beeomea quiukly 

i»viiK4><L Acoordin); to Trotisseaii, Mnrlatiua aroiils tbe lotynx, while 

diphtlu'iia baa a weU-kmuvu tendeixry to attack the niiulpipe. Tbo occiur^ 

[fwioa of boarHtMW, or tbe appearanee of an oSeiiure diaduuga ttom tbe 

noatnla. in uny oasa of acarbUina, tshould canae ua at once to make freab 

examination of tlie throat : and probably the a^iearanoe in tlie fancies of 

tbo diKy-n-hito touAb-looking mambrane ob tbe deep red swoUcn surbea 

wiU al ODOe proYt uia aocuracy of our aotxdpatioDa. 

Proifwm*. — Scarlatina ia a disease a« to tbe oonree of irbich it in unwise 

to iiidulf{« iu miiifitlent pretlictioQS ; for an attack which beginti mildly 

aaOUfb may end in a vary diflvn-ut niannar. Some cif tbe worst casea an 

[ittkoae wbiob begin ia mch a way. Sorofntoas efaildreu are bad sub)ecla for 

rioarlpt fi>vpr, and iu tbam an attack ot a^ipanntl^r mild t\-pe may be fol- 

I K)«<-tl bv a \li«traasing am«a of ooropbaa t w. Not long ago I attended 

a .vomi): !;irl who had liet'n aubjc-rt fur years to acrofnloue disease of bono 

Iu (arlim* jwlii of tlio Uvly. 8be waa taken with B cari a t ioB. The inrmp* 

tt'iDM Hin> alifibt at llrat, and for a (ortnighi tbera was no cause for any- 

thiui; btit sHtiKfoetion at the (awonlile progt«M vt the iUnesa. In tbe 

nuiKllo I'f lli<> ttiinl wrcl; all tbia ma dianged. Tbe patient lirat began to 

l^<1..l>^.iu .)f rhfumaiii-' (tauUK Sh* «aa tbm attacked in rapid TOoeeeBion 

I moua Drpbritia. iiari- Bud endo-oarditia, and doable pleimsj. 

I .. w. ondocanlili* tbeu eosiaed. wbirfa led to cerebral embolisu with 

' Wt ll(>mi)>lt■l^^ and aAeromnls to renal cmbolian. with latura of the albo- 
[ Uiiiiiiria Hud casta whh'h bntl prerioad? diap|Mare<l Tbe girl eventually 
,,AivA Btiddwilj oa tba aigbty^ioth dajr, apfanntly from cloltiug iu tlir 



piilmimikn' arlerr. In coses ■■nicti an this iliero mny bo potittiT<?ly no in(li<»> 
Uoii tiial tlie liilUerto bouif^ii cuiinw of Ibe tliseiwe in to cUau^o so seriously 
for the •xoTse. Wlifti. hower«r, the iever hits as8uiu«d a serere (orto in 
other cbiiiiren of Uie same family, ne Qiiist always be prepared for sbma 
meh cataatrophe ; and antil the disease is actually at an «iid vre cauout 
put aside our approhensioutt. 

PrAvious ill bealth front other cniiseii than scrofula does not ^ipareatly 
modity the progooaia; nor doeii enrly infniiry iotluence nofavorabty tlio 
Bourse of the diseaae. The exiu:t ohamctxrr the fever in to aaaume a|>]toiLr« 
to dcpttod upon the type of the epidemic aud the constitutional pMulior- 
ttiea of the paticiit 

The maiigiinat forms of acarlei fever ore olmnst invariably fiktaL, es- 
paeially those io which the nervous ^mptoma arc violent. A miki noo- 
tnmal delirium is not of uuTavourable omen ; and sli^'ht Av-ouderiii;; iu tbe 
daytimes if there he do other symptom of nervoiu iUMturl>aui.-L>, iiueil ex<:U« 
lO anxiety ; but if thv dt^lihum is active and pvniisteDt, vith Tiuli^ut agita- 
tioti and aleeplessuess pasaiu;' r&pidly into atapor and proetiratioB, we can 
bate little hope of a (tivnurabte iHsue. CoonilaiODS occurring after the first 
day, ospectally if repealed, are very Mnrioiia. No indication is to he derived 
from too colour ot taa nsh, forndorii tiaCof tbe eruption is not oeooaaarily 
■B unfaToonihle si^, There is caane for ffceal anxiety if the temperature 
liae contiiiuoualy ; if tlie throoi aflbciion Ite sprere ; if tliere be frequent 
aiul Iong-(v>Rtiiiuoil vomiting; or nonioiia d_\'VH)titi>ni! tliiUThnia; if at>p[iTitis 
appear early ; ur if there ho (iruat Uimiiiuli'^n vc suppn.'SKiuu of the urinary' 
McretioQ. UnnuJc qrmptoiiia are not so Derurc in the child ai they are iu 
tiat adolL At least, nooordin^ to my ex^ierieiicc, it is not ooimuuu fur a 
flfaild to <tie of uri'nnio poiaoiung, if judiciouMy treated. 

TWotm^HL — In cases where aiiy tucmber of a family is taken with 
aeartflt (erer, it ia of ituijortunce to prevent the tlltit'KS xpreading to the 
olfaen. Prompt iHolatton of the luitieut in of courae to bo iii8i«ted on ; 
and it is well, if the step can be oDuveniently ailnpled, to send the other 
efaildreQ away from tho neighbourhixKl of the aofferer. 

VaiiouK pra]>hyInct4o maasurea have been neomtofndcd to arrent the 
disMse is the incubative ata^ and prevent its furtlier dcrelopment. 
BelladoSDa, which was at one time Lir^^ly employed with thin objooU hatt 
been now proved to be usiel»sH. It tteeniH likely, however, that iu anienic 
«e hare an aji^t of greater value. It luut b«4>i) noticed that a person who 
ia being treated with urwuic c-jumot bo succcKsfuUy rocciuated ; and it is 
iWiible that tb« druef miiy have a counteracting influence uimii other 
forma of infective matter. Fraclitiouera who have made uae oftJie rometiy 
with thiaobjeotMpeiik fitvouniUy yf iUt pruphrlactio virtue. Dr.W. G. Wid- 
ford has ^ven tbe dnit< Lu-guly to chddrcu who boil been exposed to the 
iafeetion of scarlatina, aud states that out uf nearly a hundred auch cases 
in OBily two did the development of the fe^er follow, and botJi waea were 
axtieaiety mild. He reoommemls tlw ordiiiarv liq. arscnicoUa (P.B.) iu 
as Utrga a doae as the age of the child will allow, witli sulphurous ucid 
(11 XT.-sxx.), and a httle syrup of poppy- The child ahoiUd take the dose 
npUarly throe times a day at the hrst ; afterwards less iroquenlly. 

WlkCQ the disenae actually decKres itself, prophyloctio mooBures must 
of eaitrfU ba laid aside. In a mal.'vly such na scarlatina, where the gei^ 
cnl symptoms are often violent, and the complications are various and 
nay bo severe, the therapeutic measures ut our ilispooal are necoBsanly 
«wy nnmenius. Still, we must depend for ii «u«»t«ful result mora 
npoa rigihuit nuniiiig than upon tlie actual udniinistratLon of drugs ; 

' wliiB coaplimUout occnr. an often nf Koiiblo 

Bmmmtm lAl As Wfmftoae mar be, the ciaid «ltociU b» kept ia htd 

Bk • «tB-«iBlBMed room, from wbich aU eftrpet& ^riawa rugB. imahiona. 
mi othw vooBett sitidat Dot requiml for tlic comfort of tbe mtimt hftTO 
; a i ^n wal y nooved. Id onler to prevHnt tbe spread of tb* rTtwiM, a 
I nal «*< Willi a aohitioQ of carbolic acid (one part ia kaiy pMrts of 
w\ ■wirtl b« faateBcd an ns tn hang orvr the Aoor-^rvy :'aiid can 
~ ~i b* ttJdaa to dlwifapt nil excreta, soiled linen. «tr.. before tfaer an 
1 hvm th* ToaoL Tbe diild ma; bo nlIow«l to drink aa oftca M 
of pan filtered water, bat the qaauti^ taken at Mcb t^oe of 
anak b» limited. Hia diet should oooaiit of utUt, bfOth, Bght 
hread and batter, etc The lieat and irritatiea of the skin is 
f » — tt y rrftsfed 1>7 spouffiu^ tho siirfa^^ of the body aneEal times a dsjr 
vjik *$fbi valtr. and aftcrvk-artU dms^ n-iih a soft ttnrel. lliis is a more 
ptMi^at operatioQ Duiti the itiunctiun of fatH. nliidi is sometimM recom- 
Mi II till, and is qutt« aa xorviceahlo to the patie&L 

1b an iwdioarf cbho liUlc lucilicinc ia ntiuircd : bat if the thmnt is 
wm^tti, m dm^jht of ohlorst« of |)otueh mny be ordered. Should tbo 
WMft fcioomfl much iDHjuunl, and tbe cemcal glands pi the nerk sweH 
■mi W taodcr, the child should be made to suck tee, ana hot sfiplicatjoaa 
fMiwsil imil jwoltioeBt frequcutljr reDew«d) ahooU be anilieid to the 
asck ; or w* uuiv uae th(> cold compron. vludi. bseosting AMtad by ood- 
tasl with the Kk'in, tuts in tb« ume way. 0(^ tluM ^ipKad iBtamaDj, 
mUh tW OMtside of tlie throat is kept vann, often piwlaoes a npad 
M^Wiitarinn to tbn 8Tiu[)toiiiH. If, bowcTer, ibe throAt aifcotioB. instead 
g< iMSStonox, tcconiw worse, and irioe mtin p is notiesd, it wiQ be nec«e- 
SMN- Id apobr some load applicatioa to the fmctu. ^ each a obm the 
lkK«l havukj! been oaretiitW cleansed irilh a bnisb dipped in waim water. 
a atrhrtiL'tt ol nitrate of xilTer (half a drsdun to the onnee) should be 
M«|iii| irmfy to Uie wholu of the nlMnted amfaoe. Uoreonr, any 
■Mchi nlear n»j be tnuclied onc« with tte w6^ oustic. Tbe weaker 
iwprtralif VMBtoe repented everr moniiitf for llu«e or fear dajs ; and 
teliw inkrrad a solutton of oommoa all u water (half an oonoe to the 
MHt> oMi bo injected frequonil; into the fasces. Zt •■ •nry inportant iu 
ifj^ WMM H> k(H>i> llin lliroat vlean insiile, in onlv to remove iiuickir the 
I secn'tioti^ tbrown out from the Anssed ttubeci ; and fr^uent 




S—^iJ^ (V aaiKliuK »' ^^ thiuat with a aaliM oglotiQa audi as the 
SilTS.TWfc aiNotTea macus and fAcihtates the wp anrt ioa ol tooacioaa 

,,^,^.^,1,1, will b* attODdod b; markod benefit If nqotred to dtou tbo 
^• ^t'-r mxtneot, the tuline solutioD mar be ^pfiad boas ttma to tiiae 
^Mk ft twush. Ill iMlditiou to tbeae m sa impwk tUMi fc att ng i^ftlicatioDa 
^t W umU> «-» of ; "U^Ii " ■ *«^ sohitiaQ (two per ttak) of carbolio 
ImL or* ^ti>« f"iiir««'l f' ''T- ***** rhlorinat* <^ xx. to the ounce of 
kI Iu thtMo caws of eerem Horr throat it ie ftdtisahle. W IQUch for 
■kkv y4 <>{hv>r* aa for the benefit of th* pabcnt. to keep the air of the 
•«.. .!«yl witli A Boluticm of cwbotic acid (one part in tliirtv of 

r • tt >I.Lm>'» steam dnuif^tinhalet; or eaoMauBilaratKiaratua. 

■^^Mit>-<»i'Oii <*C wdpburoos addio tbe lhi<aa«.as i s ujiiuu e nd ed hv the 
^^Kril«<wf<i4^ IS tihw nscful This rvmmlr Jbo^i ho ossd wiUi an 
TTSwr ao.1 tho «i I, put* or .UluteJ with aa aqval ptopottion of water, 
•SmZi bt H«»v<'«l iu»<> tlie throat for a f r« ■ooiata* rvnr two or three 


*^rt«o l« ««r™. "w »^* «'*•'*«* "V** iV"*ri into the nasal 



or tbe tiO!ie nui^T he Bynng^A ijium) a Am nUli a wsak sulutltm ot 
of «ilT*r (gr. V. to the oiiu<!n). 
Abscesiics foriiiin)( iu thv iicck munt be opcnod, directly ductuation ia 
iMerted, and be aMc-rwRnlu well poulticed. If biBmorrbage oc<!Ur, tlie 
vautitl iwast hv etuffvd with lint soaked in percliloride of iron. A post- 
pharyngoal nbseess maut be also opened early witb a largo trocar and 

If oIorrfacM be noticed, the moaluu laiifit Iw Hi|Tuig»<1 out frequently 
daring the day with n-».rin witter. If tha tympanic membrane be perfect, 
Um dkiflcliarge proceeding onlv from tlie external canal, a ayriii^'ufvil of 
some mild afttnngeat lotion kIiou]<1 be injected each time after roiuplete 
cleaDHtii^. Glyceriiie of tannin (one drnvbrn to Uie ounoe of waUii') or a 
weak Ablution of Bulpliat« of zino (gr. iij. to the ounce) answer well lor tliis 

Ill the case of any of the ahoTO coraplirationii quiiiinn in full dos«« 
(pr. iij. four time* a dny for a chiUl five yea™ old) slioiJd bo ^vot\ ; iind 
a liberal diet should bu idlowcd, due iv-gard bcin^ bod to Utv patifut's 
powers of digeation. When tbe tempcratuire hns fullcii in ».\u:let. fever 
tbe ehild fthoubl hu-t-e metit once a day, nu egg or ii little bacau for liis 
faKttklaet. and should take plenty of iniUi. Xa long na tbe water con- 
tinum clear we muy be huvc tbiLt be is uut beiii>^ uvurloadc^d with food ; 
bat tbe appearance of u lbiL<k depcKtt of Ulhattti tiliould lU oucQ uiuke uh 
teconuder his dietary, and Umit tbe quantity allowed at bis meala 

VSlien tbe throat afTertioa ia severe, iron seems more bsn^cial than 

qoiniji*, if aibninihtered energetic-ally. For a chiltl of tina a^ liftt«n to 

^enty <lropti of thu jwmitmto of iron should be ^roii with j^lvfcu-iue aud 

wmter everr three ur four boui-g. At tbe same time bi-aiicly-ond-egg mist- 

^^ nre moat be supplied in Hu^h €{i]antitieH a-s Neem ilc^nrable. according to 

^■UfO dejTTce of proMtmtion of tbe patient. Itl s\h'\s ctinfs e.liildrea will take 

^Bvith benefit largo qtiantitieH of the stimulant Strong beef-tea, nient 

^Bextract. etc., can also Ih; givou. 

^L^l] tbe diaease be ushered in with obstinute Toniiting. tbe symptom ia 

^HpUl velieved \ij sticking ice. If diarrbieu occur, oxide of zinc (five gratoH 

^^%rA child of fire yenivt old) or bismuth (gr. xv.) and chalk mixture suouM 

be rv sorted Ut. If iit tbe b«giuiilu{j[ of the diarrbtea tbe motions are liuupy, 

B mild a]H>rii-ut, tiiiob us a dose of costur-oil or a rhulxu'b and soda powder, 

Ethoulil be admiuietored. 

In caaes of malignant scarlet feyer with Tinlent nerrouH in-mptonts 
wry kind of trr'titmeot will unfortunittely he nftfii found to fail. If tlie 
tatspemture be hi;<b, it must bo reduced by <«i1d bfitlini);;. The cbiM 
may either be pLu-ed ia n cool batli (tciuiromturc of 70 Ftibr.), imd kejil 
tli«« until his t<>eth begin to chatU-r ; or urtVuuuns wltli watt-r of the tuinie 
temperTU.ure timy bo praoti-wd, uh recuimueuded by C'urrie. 1 prefer tbe 
(onnor iuetlio<l ; uud thei-e i» no doubt that tbe iiatuediale effect of the 
both in loweriu<; tbe pulso uud (vrnperatiirc, di^pitluij; the delirium, ami 
nljri>~ing tbe agilntiou of tbe ptitient is very deeided. When tbe temper- 
latore rises ngaiu and delirium returns the process must be repented. 
PTnfortunaleh^, although there is tem{)orarY relief to tbe aymptoms, ttte 
it is seldom eured by this means, and usimlly fidU after n time into 
of [iroxtnttiou and oolln|)«ie, in which he ilJeK A milder way of 
ttw same trentment ia to t^TAp the child in a wetted sheet, and 
upon a hard mnttreRH. cnvering him merely with a tJtin blanket 
looaely over him. When Ik- Hhivers he slioiild be relaqsed aud 
to his bed. The milder prnatico U RuitabJe in tbo less tte^-ere 



OMCfl; ABd has n diftiiK't elfeot in reducing; the temperature. It must I>o 
remetubereil, ^Kint-wr. nitb ref*iunl io ibis qiwstioii of lijper-fyrom. thut 
children oft<>u hvar hif^h tnnpentturM \ert well ; and it is difficult to l&y 
down & broftd ml« ae to tli« period at "whidi it is neoeasarr to intervene. 
Ii is lietter to be gnided in thiB respect br the jreoerol HTiuptonifi than bjr 
tlie Ihfnnometer If. ns often hafpenii. a rliiM wmma conifortAble ntid 
cirnpixcd, wiUi a trmpcmlurp of lOo" or 100°. tbers is no ot'cnmon for luty 
^etepniurc eneri^tir tbnn Ui&t of spaugini; tho sorfww of Out bod r with 
water ; bat if nttb n lowrr ti-nipentaire (lOS* or 104' I hv is dclii-j- 
oDfl, Bgitftted, and distrauaed, the cola bath may b» iiset) mtli bi^iipfit 
Wet packing i» often umful in tb««e caMs ; but -wbeu Uiiis cuvrlojMrd in 
hlankftn tlic cfaild'n tcmpi-nttiiro mnst bv RarefollT wntubni. If tliL> Hkii)^ 
be indulged to net. hr this means, nnd the patient Kwest profnseljr, tfac 

18 a ben«fieud od« and the temperettue will Ml. If, cd tbt] 
tbor fanntL the akiu do not act, tlic ofTect of the pnckinf; is to causa 
further iudvatte iu the pvrt>iia. Therefore, if thf> t«niix-nitun> b« fuuml 
to rise instead of falling, tlie lilaukets tthwild tw at mice rrniowd. In 
ftQ these casi^s tbe both, of whatever bind it be, should be BUppkmonted 
'by enei^getic stiinulatiou id order to coimtenkct the t^ndencr to sodden 

: tbe child is from the first in n state of pioetration, instead of tbe «oM 
bath the hot musttml bath Duiy be tnaile uae of ; but aiKsh caaasarc Hcldoui 
benefited ^-wn temporarily. 

If rhPuniAtic paintt ar« compUincd of and tbe joinla xvell, tbeae parts 

Id be wrappcil in rtotton wool imd ro\Yrf<l «4th n tirtulr applif:<I flnnnt*! 

: and Dovt-r'tt powdrr should be fnvcn at iiit^ht if tlir jnins tutt-r- 

I witfa sleep. Attention must also be paid to the stale of the bowela . 
UtatnmAtioQ of the twrous tnembranes must be treated upcm ordiiuu^^ 

If idbtuninouM nephritis occur, energetic ti>MUm«nt must be adopted at 
A mere lni«e of albnmen, eitch as is often met vrith in <»aps of 
'ecariatina, ift of little oonspquencip, and requires merely tonic treotmentt^ 
l>nt the appearanre nf coihoub albumen in a tunoky urine ahows the 
enee of ni>iite Brifrht's diRease, nitd iit a very ditTcrrnt matter. We should' 
tbercfon- at once proceed to sn-ont and pur;;o the petirat. There is, per- 
hap^v no condition in which the beneficial inHucnce of free pnr^tion is 
more Btrikinff tlinn in tliis oomplication. A cJiiid of fire years old should 
take every nij^ht n diwft of coinijotind j-ohippowdiy (gr. xss--xL) alone, or 
mixed with live i:prains of roiu)>oiuid wnniiDonr powder. Eunu^'h tdiould 
l>e (^Ten to produce two or three tcitetr BtntiU. In the diiytime be aboold 
be wrapj>ed in a ah<set wnmp out of tepid water nnd l>e tlitn well paoked 
in hhmlfetA ; takiii<; at the same tiiun a dniu{rht contaimuu a aolutioa of 
iict-tate of iiuimouia ( * ]- 1 and antimouial wine (ill xx> to maun tbe &«• 
Hctiou of tlic nkiu. His diet nhouhl be simple. As lon<! as there is anj 
p,^-r<^xla no Bolid food !<lioii1d be allowed ; ana the patient should haro noth- 
iiiR but milk and bmtb with dn' toast. PlentT of thiid is usefid. If tbeoe 
mrosurfs hr ndoptt'd. the allnimen in the majority of cokos will be found 
to disappear toit qaickly from the tirine. Should it, however, panist, and 
iUe rcnu disorder fteem to l>e pMsin^ into a chronic state, iron and erf;ot 
ore indicated ; or lltree grainx of lira hTdrate of chloral may be ^ven (for 
o child of fivft yo»T» old) throe times a (fny. In CAHen of tinrmip conrulsioitK 
piirn:ing and awenlinf: carri«l out bripkly are of equal ncrviw, and will 
usually quickly relieve the irmi])tom», especially if aided hy a diuretic. The 
ioUowing ia a serviceable fainu : 



9- Liq- ninmoniiD Acetalis HI xxx. 

IVtAewi.- ncctutU gr. y, 

Bpt jimiporis ill t. 

Sp. Ktberis mtrosi 1^ xx. 

Q^carini "l xx. 

AqouD ftd ^ 8fL ]^C. Ft hiiiistus. 
To be taken erery four houra (for m child of flT« j-ears oM). 

A e<>0(l diuretic for children is <Ugitalis ; and the dru^ is 'wcU bornu iit 
•arly fife. Fire drops of the tincture given three times n ilnv with an euijiil 
qaautity of spirits of juniper may lx> einployed. Jtihoramli nml iIh idkalLiid 
piiocarpiue an utjcful in theM 0HC«; and con be giren either \>v tiie 
iDOiiUi or l)y Hu1>cutaDeou.<i iiijectaon. The monb coovenient war of nalmiii- 
LMtrKtion is tn nuiko n fresh Bolutii>a of Uie nitnite or hyilrorlilnrnt* of 
pilocnrptnct in mtor of tli« sfcroQgth of one grain to tweiily-foiii- minims. 
Ot this solution three dropa {ooo-eiglitli of u gruiu) cilu be injected »ub- 
cntaneonxly, ami is a miitanle doH« fur a child of five youri of ngc. Children 
bMT this remoily wclL Jf the nuhition is freshly made, copinus Rweating 
lolknn tlic injuctiou ; thtrc Li often profuw snlirntton ; and tho wcretum 
of niiae is groidir sugmented. The child should he bct\«-ecu blankets, so 
as to enooorage the action of th» Hkin. Tlie dose niay be repeated every 
daj> if necesaary. It oft«u excit«.'B nausea and ^'omitinp, but this is imiua- 

Daring the stage of desiniAm&tion measures should be taken to hastim 
the separation of the epithelium. Tlie child should bo oiled nil over the 
bo-Jj evorv uight \vith curboli^ed oil ^ono part of the acid to twenty parts 
(4 olive-oil), and this should be well ruhlied into the akin. Aftemmi'ds he 
should be tborouf^hly washed u-Ub soap in a varni bath. If this be carried 
out in a vranu room, there is no itrox of a chill. 

Even in inild caaes tlie child should keen his l)od for three vreeks, and 
hi* room for a month nt least, from the beginning of bis illness ; nnd until 
the peeling luw quite ooasod tJin pntirmt is unlit tn nstociaie with hejilthy 
pCTmmtL It must be remcmborod thnt desqiimiiutioii may linj^-r lou*- about 
the mists nnd ankles, the fingem and tlio toc^ : and that a cunsiderable 
time may elapse Iwfore the mucous membmtie uf the tbi-oat has cumpletely 
ncoTtmd its normal stutc. '^Vfaen the child ia finally prononnced to b« 
wdt it is ndvianblc tu ucnd hiui tu the si^ii-niile for change of air befcHn he 
Us ordinary habite and mode of life. 

citAPrm? IV. 


Cbiiskk-fox or vnricnllft is Reldom aecn except in y nong Hiibjectfi. It ia nu 

,' iufootiotw dUordi-r nliich occur* ^euerally iu cpidL'tiiics, uul nttaclu by 

I preforeuce cluUn-u natsl from two to aix yean. At one iime it nnn Bup- 

' posed to be a form fjf luotUBed hhiuU-jkix. but fuw are now of tliiis opinion, 

for tli« evidence against it ia ox-eruliubuiii^. Attempts lure been made to 

impart the ilineiise !>)' iiiocul-ttioii, liut nitbout ttiicceea. 

Jii/mj>{otn3. — After a perioil of iwiibiitioii, Tsrying from wveii to (our- 
t«eD (lays, tbo child ix uoticod In b<> fivc-riNli, ood within the next foiir-aud- 
tweutr uoui'8 » number of Hmall ri^x^-iW siK>t« appear on the cL«at aiid 
OTor the BoiIt generaUv. Tliese are slightly ele™t«i, aiul nnmbcr on tlie 
drst da^r liftei'n or twftnty. In tlie eouTHe of a few linunt —in nny «we bv 
thfi nest iiionuap;— tbo ])apuln hns dianped into a v(;sio4e or roundub blel> 
wbich in filled with cluur Mrutn. It ban sumiUuic-ii a very [juut pink 
on-'ula round )t« circumfereQce. At the muua time ntlter populcH bare a[>- 
peiu-ed, more unmeroiia than on Uie first day. Tb«ie in tbeir tarn bix.y)tno 
(M>uvfiirt«tl into dvor blebs. In this way every monitu<; tiiiils a &e«]i crop 
of nd Bpot** Add of fn'Mli bleb» funued from tbo rrd iqwtti uf tbo pruiiioua 
day. The change from red spot to bleb may tuke plitce verT" qoiekly : in 
fftcl, the rash Ems eometimwt been deachbed aa vesicular from the first, 
. any caao it ia compl«toil within (en or twelve liount of the opptuiruice of 
'the nd pnpide. The Kpou apjienr in no regidur otxier, but oro scattered 
alxmt all p:irtM r>f the boily and limbs, and may even bo seen bene&th the 
bair on tlie hcaljt. Tliey are al»o occanonally Eoimd inaide the mouth, 
on tlie soft iniltttr. tlio inner side of the checks and lipM. and at the sides 
of the toiiifun ; but vrlicii sf.'tfitod on uiueous memliraue tlio vosicle chUDgea 
rory rApiiUy to a t^mAll i-ouiid uloer. Ait«r a]^x!ariag in BUccMsive crops 
for four or 5\e days, frenh spotA cense to m seen. Tlie changes which 
each indiridunl Rpot under^^H are as followa: — it IncreasM in nze for a 
day or two, and (lion it« liquid content**, from dear, like pare ti-ator, be- 
come milky. Borne bnntt imd form croifta ; otbern prtiient, ufter a dar (h- 
two, a speck of »cal) on the summit, which to a baitty glance gives a ndso 
jippeiu-ance of umbilication ; the Tefticle then drieiH np and leaves a thin 
mist. wLicL falls ofl' after a few dii3DL No war ia left, aa in vaswls, iTTllflsn 
the child have irriuitcd th« Hkui by scnttcbiu*.' ; lu wliidi case a aladlow 
pit may be seen in the Hituation of tJie scab. It its ilifGeidt to prevent the 
child from scratehing the «i]>ota, for the eruption is accompanied by con- 
sidcmlOe irritatiou. 

The amount of fever varies. At tlie beginning the temperature may 

rise as high aa 102", e^>ecially if the raeh is slow to appoar. Aft^ th- Hr^t 

F4ay or two, however, ttie uyresiu aahndee considemblr, and ia BcJdiim 

higher than D9.5° during the reiiiaiiicler of the illnesii. In aomo cnBes a 



it exaoerbfttion owiurs with the mntumtion of the vesidee, but tiie 
ipenture soon rctm-ns (« Hip iioniiul level In tlie larjfe majority oi 
owes the <<nR.4titiition!il i]isturl>an<^e w of the Miglit^^Rt. Afb«r the cnists 
Jave fiUlcu the t^-mtxHnitiirn ainkn to n lower lovnl tliiui in liealtb. 

The (lutnttou of liiv dinonler iii tou Huyis or a fortnight, cuuntins from 

preliminary lever td Ibu tliiuJ full of tlio cnuitti. Aftei-wanlH the cliild 

/ be kft la a weakly HtaUj for some time ; and delicate children niny 

iTe tbe oullircdk of serious diseaae dct-ermiucd by this nppiuvutly trifliug 

plaint. ThuD, I h&re known nv»\e tulx*ix'iiIo)iiif to »uc4!e(;(l aft«r n verj' 

ioten'sl to aa attaoJc of chiokt-u-jiox. 
In ezceptiooal cases the complaint is not over so quickly, ilr. J. 
utcJiiaHOD wftH the tirat to drtiw iitt«iitioR to tbft gangreuuiiK eni|i1ion8 
bicb Bometime« occtir io connection with the chick«n-pox. This dtn- 
rouH aoiupUi»tioi) iu not confinul to wotUcly, iU-uoun>;h4>d childn-ii, ol- 
h it in nioHt nommon in them. It is no doubt coiiQecteil with the 
tendency to RpnntaneouH gangrene BometimeH met with in chil- 
Uld dMcribed in itnothrtr chapter. 
Ill gaasrcuoiu vnncclln the vo^clrs, instead of dryin^r up in tbo ordi- 
T w»y. become block and gei InrKtr, so Uiat u numbt-r of n>uu(l(.-(l block 
im, with a diameter of huf an iiicb to lui inch, lure scattered over the 
itnrfaM* of tlie body. If a ncab be reinoTed it ia Been to cover a deep ulcer, 
luid it the akin is of a dusky red color. Ail tlie ^'eaiolea do not tiike on 
gsagrenoas action, ho tluit wo find mauy vnricellous scabs of onltnary 
,oe mixed up with the blackt^ued crufilu. The •'au^^'reuouB process 
teu {>eoetrated deeply through the akin to the ma»cl«s, but under aome 
if the acaba the ulceration is more alinUow. Theae cases are vety ftital. 
Kr. WiuTin<;tou H'lwanl tios reported tho cohc of a weakly bnby of twelve 
ntootbfl old, wbo weighed only six pounds and a half. This child "waa at- 
tacked with gangrenous varirella and died in a fev days of pyiemia with 
•ecxtndary alixremes in tht? lungs. 

Dir%{inim». — It is often n very difKcndt mntler t/> diRtingiibth between 
diickcu-pox and luodiiied smidl-pux. li the i-ruptiuu follcpwH vvn- rapidly 
upon tlic first Rigna of fever, the diwaso is probtthly varicellii, for in the 
case of varioloid the rash is usually precetled by two or thi-ee daj-s of fever 
and taaLuse with ^'ouiitiUK ; and the pain in the back may bo 08 intense as 
tbo ttnmodiiietl form of tho disejiae. But there arc many exceptions to 
rule, for in aome casivt of rarioloid the nonuol dutntion of tlie pra- 
iptive peiiod ia coa^d<>rably tihorteuod. .Vgaiu, the spots in varioloid, 
in Tariola. are ptiopi^il in tAreea and Gves, while in vnncella tUoir distri- 
bntioo is more irregiuar. Tlieii, the pipiile in varioloid ia always Hliotty 
and han). In vartooUa it iH jioniiliariy nofl, and alwayn disnpjjeara on 
tin^ tho nkin. If thoro bo nn clovalion \ei\ after the fall of tho scab, 
ucliisivo in favour of znodifieil amall-pos ; while a subnormuJ ti-m- 
ure oo'iirring aa enrly aa tlip tcnili diiy wonlil point rather tovariL-cUa 
to varioloid. Aecorlini; to ^Ir. Mtciniii, the variwlloua vf^iole in uni- 
locular, and can be cia)>tit*d by rutt; touch of n nei>dlo. The wsick- iu 
pax. on the contrary, is ahmys niiiltiJocular. and cannot be emptittd 
ly a single puncture. In case of ctoubt thia difTercnce will servo as a (lia- 
guiahing mark. 

It is important to be awnre that a Bhaltou* pit or scar may be left here 
mod there upon the akin after undoubted varicella. Pittiug may occur 
in any case where, from the irritation of oontinued acmtching, or from 
■ome coDstitutiooal peculiarity of the patient, utceratioQ of the akin hnJL 
bsu HBl up iu tbe site of a vesicle. 


Bis it 


Gn^nnoasTanceUaisdi^iiigiusbedbytbefaiatoryofthe ease, and the 
iyr« ne» ot ordinAiy TuioeUonB scabs mixed up with the blackeiied and 
gmgmtooE eniate. 

T t t atm e m L — A diikl attacked b^ cfaicksQ-poz nnnt be removed from 
inhri diiUmi, and prereated, if poanble, from piddiig or scratching the 
ipita. If thara be much ferer, he should be confined fo bed imd his 
bends mat be attended to. When the disease is at an end, the child will 
i g qaii a a loni^ sock as quinine or iron. If convenient, he maj be taken 
to the B— ada ; and if tmre be any conamnptiTe tendency in ih» family 
dacge <rf air daring cODvaleeceooe is not animportanl 

la ease* of gangrenous Taiiccfia little can be done berfcnd snmtorting 
tke afaength wtth good food soitable to the age and degree of feeUenem^ 
the patimt, and giving the tvandj-mid-egg mixture as often aa is required. 
If the gangrenoofl ermrts are few in number, the aeabs maj be remored 
^ri the onderiviBg oloer filled with iodofonn powder, as reocnumended bj 
Fterot tor gangrene of the vulva. 



The cow-pox. or TueriniA. is n diiwHor with i« □afeund to tlie mik'Ii coir, 
boi DCT^r nrouni in tbe buiuuu Kiihjvct E-xcept us the result tit din>c]t 
Wtioii- iu Ibe oow it *ppeAi'(i on tlia teHta and adder as iBolat«<l spot . 
wloeh ai Snt are papulnr, but aft«r»anlH pem tbnni^ Ui6 vesiculiu* aud 
purtolar BtagM, nx in lni« niimll-jiox. Thej web ou th« tbirteentli or four- 
teeotb <)ftt-. aix) Ml uTTin tiio rolliiwin}{ wotiik, lofivitiff pits ou th« «kiu. 
This diaeafle in now HutislocturilT proved to l>o the rent &inaU-po;i, altered lo 
dwracter iuk^ iar>lified by its |>iuifttv(;a Ihroueh the animal, but xtill oipnble, 
wkm eoovttyod to the human Kubj<!ct, of imparting lut iniiflh pi^itectioa as 
would b« deriTcd from a direot nttnct: oi tho original tUwaw. 

U in now a famiUnr ntory hoir Edwai-d Jenncr. tlicaUving an npinwjitice 
to • Mtrgeon in <ilonceiit«<niliin>. determined to invoitigsts the truth of a 
bolwf, <nUT«>nt in the neigb^Miurhood, that milken vfbn bad bBOome tnoo- 
Qlal«d with (MVi'pox iu lh« pursuit ul tlHitr ualliug, wvirtt uu loDf^er ntactip- 
tible to the L-onlji^ion of xiiiid)-]H>iL -, tmtl Luw, by cjirt^fttl obfvrvatiou and 
evperitoeut. he Kn<r4.><>4Hl4>il in etitAblidhiu}^ the iuiportaJit ct)u<-liisi<>iiti — ^tbat 
ooiF-|K>x commuuicated by inoculation to tlis huiuau subjact did actually 
ooler imiuuiiitj from aiiiall-pox ; alto Lhat Ibf^ diseaHts m) engi'after], might 
t« tnnMiutt«d tDdot!Rit(>ly from ])ii>nion tn pt/iwm wiUioutniiy ftlwitemontof 
its prot«etiT« power. Since .Iftnri*r*« tinip the pmctice of xnu'innation luia 
beoime u&iTemd, nod to thin {oroni disooTery weowt; it that amall-[>ax, bk 
it otad to be, with all ita dreadful conaequenceM, ia idmont unknown in the 
pwMPt diw. 

BytnplomM tnd Oo«r»e. — A(t«r the introduction of the lymph uader the 
■kin of a child prerioualy unncdaAted tibe foUowing ia the course o( tbo 
uulooed diacmler. For tn'O days no change tAk&s place, but nt the end of 
the tecond day, or beginning of the third, a smsll elevated pn])ule is seea 
at the aite of tlie puocture. This enlarges^ and by tlie tiftn or nxth day 
baa beooms a dreular raised pearly-gn*y venola, with a iVpr«>atijon in the 
oentrCL The venole ;*rowH, and by the eighth day i» fnlly dovaloped. Itifl 
Iben a«en ana flattened, round, Kray-oolored vesick, still dcpreMd in tho 
c«Btni »nd fltled with a cnlnrtess lymph. It dofin not remain stationniy, 
but beffizM At ODOA to loae it^ tniii(«p«uron(!y ; a n^l areola foruis round ita 
btM aik) i^mckly ^read«, »o that by tho troth (Uy t.lio v<>ait<U^ ia fointd 
BHktetl oo a lianirnetl red base, wilh thn rpd areola extt-ndiug for one or 
mora ineben orpr the Kkin around. Tho venirle has now bei-xime a puKttde 
with pumhtnt oonionta, and around it the aiilH^iitaiienua tiasue ia bard and 
BWoUen. After the tenth day tho areola gmdually fudon ; the duid voutenta 
of Um poKtule underao abeorptioa : and by the fuurteonth or fifteenth day 
a aeab naa (inueil. wmoh gradually looaeua and becumea detat-thed. Tim 
erant usually faU« in about three weeks from the time of puoolure, aad u 
ita phife ta oeen a rooad stmkeu »car xiitted with little depresBioa& 



Tbo diseaeo ia at first purely local, hut afl«m-ar<la becotaea genurnl 
According to Dr. Squire a continuous viset nf teiii|)emtiir« begiu» ou ibe 
fourth or fifth ilnv. Tlii» sxidiU'uly incrryises c>n th« eif^btli day, and na 
Biinlilcnly falls a day or two afterwarcte, when the rkoU has pcuwd to ex- 
tend ittielf. Tlia maturatioii of the vcaJcle is nlw) nccomiKinied by otlicr 
si^R, sbmring tliat the diwfuw baf) l>egUD to nffert the system. Th« child 
IB rr-stlniM nn<l iinofucy ; then* is tamo digmttiTO disturbance ; And tlie 
1^-iuptuitic glnndB lo tlm ftrmpit become luiidur. Sotnotimce a zoaeolous 
red raah makes its n[)|)f>aruice on the afTectod limb, nud msj extend to 
the other extremities. 'Iliis rash may become papular or even Tcslculnr. 

The above is Lhu vuurec of the wbcoso vrhen tlte inoculating lymph is 
(Aki-ii from niiuthcr child, iflomo pnu-'tiUonDrs prefur to u»e lymph o\y- 
taiiitHl (lirL'c^tly frcjio the cow. But vith " primary " lymjih tiiert> is otore 
difliciiUy in oiifrntiiig RiicceBsfnllj; nud when the vatt-iimtion tiikofl eftect, 
the cniiNtitutiotiM Hytiiptoiua are more severe. There i« al«> %nollifr ilif- 
fereiice. Vr'ith Kuch lyiupfa tlio whole prooem is retardeil. The papule 
does not appear unlil u -weak or oven n loup;er time has eUpsed, and the 
(urtola doM uot become complete until the eleventh or even (be fourteeuth 
day. The sn-elling and hardness nxound tlic pimtule are f^'vater. and the 
BBcxmdary raabes are iitorm frCHjueiitly tieeii. The Hcabbing titMge Is also 
prolonf^od, and tlio cnut may not £aU' for a month or nx weeJn ftom the 
day of upcratioD. 

Even when humanized lymph la mad« use of. tbs pioc«ai ia occa* 
siunally retarded. This may be the (»se nheu d^i^ lymph is employed, 
and ia iuvariably seen if the patitiat happen to be incubating mea^Jo's or 
nrarUtirin. Hometimei<k too, it appeafa to be owing to a r^iiKtiltitiDnal 
peeitlinriry. )Ipro r^tardalioii do(« not. bow«rr>r. ^oct the value of the 
result if the development of the itidU4-ed dtsefiAO be noraoaL Instead of 
being retarded, thp pronesn may be accelerated ; but this, again, is iniina- 
terial, provwled the co»n»e of the port be regular. If, howerer. for what- 
evor reason, the eoiuwe of the diBonw> tw not rogid.'»r, and th« poek b« in 
any way inniinplelfl, the remiU must bo looked upon an uosutisEactorr, 
and the prot*'clion so afforded cannot be relied upon. Vaccination is apt 
to bo rendored irregular by tlic presence of acnte febrile diaeaRO ; of 
diitrrbun : or of certain skiu tliacaaes, eepeciaUy herpes, eczema, iotortiigo, | 
lichen, and atrophnluH. In all such cases, directly the child's health is 
restored, the ojieration should be repeated. Uuforlunatoly it will then 
often fiul ; for after a spurioufl vaccination tlie child may be left— tem- 
l^ionuily, at least — iuBiisceptiblo to tlie action of Iho lymph. 

In cases of revacciuation tha result is often iircgulAr. The whole 
process is then hurried. The papule An]}eiu« viirly ; tbo vcacJo is fully 
develoiwd by the fifth or aixtli day ; and then lit onee deeUneA. On the 
Mghth day a scab forms, ami bea)rnes detacheil a day or two later: so 
timt in less thau ii fortnight llio disease has nin thmngh all its stnges. 
With this, the constitutional fffTnptoms are more severe, and the itching 
and local discomfort greater, tnan in cases where the inoculatioD is pnw- 
tiaed for the first time, 

FfxtUvtiiy: Falue of Vaccinnfwn. — KfTectuaily performed, raccination is, 
in the majority of rohcs, a permanent protectiuD ngaiost BniaU-|>oz ; that is 
to Hay. the protection afToi'ded by it is as great as that furnished by an 
actual attack of variola Jenner hiiii»eJf never claimed that it would do 
more than Ibis. As a rule, au individunl who has been suooeeefuUy and 
sufficiently TiM-rinated is either instutooptiblv to Uie contagion of small- 
pox, or is capable of takijig the disease only in a mild aud modified fonn. 



It ia, tbeo, venr important to oBcertalc vth&t constitutes an pfficiHut vac- 
eination. This (jnestioQ haa boon anewei-ed by Dr. Marson, who fouod. as 
a result of thirty yenni' Dbaerration of 8itiAB-]>ox cases in the I/ondon Fever 
Ho«|iit«l, that while iti uiivarciiiat«<i ptinniift the mortality was as bigb ae 
87 per OPnt., the ]ien'eiitapo gi-n(iu»lly diniiiiighct] in ^•xftct proportion to 
th« Dtuuber ooil oomplctoucstt of tbo TOCcdmitioD dcatricu ; so that in 
pereons tvbci coul«l tihow fnur or more well-marked scara the mortalibf 
WW only .55 per aant It Klinuld thprofore be the aim of fiverr vacxauiitor 
to protlncft four or tive peiminft wnll-ilf'TfOnpcd vesielcd upon the ann of 
the patbcnt. With Ii;nt( tlmii thtis niunliGr thu viuxunnliou, iilthou^h it ni»r 
' be BuocesHful. ciumot he roiiHiderud to be Nufficdent, nor the prutc^ctioii tui 
eotDpI«t« as it oiui he tuude. Ah b further preL-autiuu it is usual to re- 
Yaociiiaie tL« imliviilitnl uftt^r be Una iittoiuoiJ fLe age of puberty. Bhoiild 
liiiH he im)HhH.xri»tui. it i» tuiTmxlAv to i'4>pi*ftt the operntioD if at any tiniH 
the piTBOii Lvcom« liable to be I'xposwl to the i'ontagio& of enmll-pox ; 
eapecialb if upon examiuation of the arms he ia seen to bcAr only imper- 
fect eTiaeace of a fnnuer vaorinatioD. The nrotectivYi power of vaonna- 
lion ia well se^ri in the following Ajfurps, kintUy aupplied me by my 
hviid Dr. Twiniiip. Tho cnwa were under the care of Dr. Gayton. of Uin 
Homerton Siu»ll'{ios Huspitnl. Behreen 1671 and 1878, 1.574 childr<'ii 
came under obscrvution, suffrrinK from amall-^x. Of theiw. 211 had teen 
«ffieieiitly vaeeiaated, and ouo of thpin died : 3'Jfi liad Iieen impeifeoUy 
racciufttvd, aud of tlic-su 31* died : ITS) were 9«iJ to have lieflJ Tucci- 
uute J. but bon- no luiirks ; of thtso 46 (Uf(l : 788 wcm kuowu ufver to bava 
been Tiu^iuitcd, iiud of thoHe .tK5 di(>d. Takintr Uie last tno grouiM to- 
gether, the mortality in uuvacciuated rMldren wtw 44 per (wnt under t<?n 
years of age. 

ifeUiod of Vair-inatiiifi. — The lymph used atiotild be tnken from the arm 
['Of a henlthy child at eotno time )>otweon the eixth aud cif^hth day of Ycsico- 
jtion, wbilw tho ruaiclo still retains ita purity and trauspw-ency. Aft*r th* 
vi^'hlh day it should not be uhciI. The child, the subject of the operation, 
, ahoald be in good healtli. If he be poorly, expeoially if he be feverisli. or 
I be KUffering from some skin ciii])tion, the operation should be postponed. 
WM JeoDor'fl own dirooLion to sweep away all eruptions before inncrtint; 
I lymph. This rule is a very impoi-taiit one. for although the vamua- 
'iiOD may possibly take eOect, it is more likely that it will fail, and a spurious 
Taocination may reiulei- ihu child'u system inauKocptiblt: to the vaccine 
lymph witlKtut afforcbtif^ Ihu dcsirit] pn>lx;cliou at^iiuHL small-pox. ftlony 
uetliods of iuHi<rting the lymph ure now in use. Tha fiiinjilost, aud iierhAp» 
I the best, ia to make three separate puuctures on eaclj nrm, inserting the 
I jMiitt of n perfectly clean lancet, uioiHtfiied with fresh I_viiiph, stifBcientlT 
I ileeply to dnw a little blood. In nmkiut,' the punctures the skin it atretohed 
IwtWMin the finger and thumb, and the jwiint of the lancdt i» lucliiic-d dowu- 
wanls, so as to enter the skin obliquely. If frt-sh hiuph i-.anuot be ubtuiucd 
irom the arm of another child, lymph Btoreil in capiliior tubes, or «lried on 
tirori,- points, may lie used. The dry points must be first well moistened 
with wat«r, and then iusurtod into lli« puuctures moilc by the lancet. As 
many should be used as thoro ore pimcturcH made : aud the points should 
be pressed down into tlie little wounds and allowed to remain forn minute. 
On bein^ withdrawn, tlioy should be preased against the sides of the punc- 
ture, so as to insure tlte hnnph bein^ left in thti Kkin. 

Otxanoiinl Srijuelce o/ r«OL-iiia/w".~S(HitetimG« erj-sipelns lias been set 
op by vaccinaliou, and even pya-mia h;iH Ikh-u known to follow, and enuse 
t£e death oi the child. Theb« luifdituuate consequences are not to be 



attritmtod BB flW MU Tly ti aoj cargl o —p eoi or awkwardncaR on the pmrt of 
ibe opeiator nor to aiij impurity in Uie lyupb emplostcd. They ue dim 
to the cuuHtitutioual stAle as the child nt the time of the operation — s titate 
in which the punrtur» uf the lancet is foUowotl by theae tmtowaid aociJeiita 
Just ia auy oth«r Iridioi;; opecatioa mi^ht b« followed bj thatn. A rosetilous 
and paptilnr nwh tuts b»ea Hlrea«iv referroil t<> aa someljjnes foUuwiog 
Uw lauturatiou of tha piutula : but othor nuJieH. wiich as eczeuui luid the 
variouB ekiu eruptiona to whi<>b children aro liAblc, nuiy be seeo oftarj 
[TBCcinnlioii. TIk-w rashes ai«alivnyHaltTil>utedbji'pnreot« totheinawtic 
ot tba vacx-iiiA I v'mi>li. In nODie caaea TX't-inatinn tntiy hav« l)ean indiroctly ' 
a oaiwe of tlm mkin ofEoetion bj lowering thf rhildg general health — a 
refloU which in chih^hood ia apt to follow anj fcvnisU uttnck ; but oft«ftJ 
tlic occurreDoe of the eiuptioa at a abort iiitcrTol iiftcr the raccinalioD i» ai^ 
eouicidencw, and is owing to an cutin.>lr difierent caani. lu oiit- 
lUcnte' rooms of boapitob it ii Dot uucotuinon to find even icabiun attrib- 
Qted to a rvc-ODt THCtiDatiou. 

SyphUiH »D<1 u-rofuhi ar(> xaid tu liuro htnea ruu^'«iyed from child to child 
by the raccina lymph. With reg&nl to the Unit of theae dioeoiiM, it vu 
loLg dfiiied Uiat Bucli tnutsmisaioD was podsible. Experim^ita were nad^ 
ami iu Franca children were delibaraiely TaooinAtt>d with lymph taksn] 
from otiier childran sufTcring from tnhcrilod syphilis ; but in no case 
syphilis found to b« commu&icAtc<l by the operation. Many case^ boiTp-j 
ever, liave lieen since publinhed whicli leave no do<ibt that ooaiiDUDieiUion 
of (ha ^phililic virUH m&v tHk4> plaoe by thiti meajiH. Tite old notion that 
tba foot of ft vacciiM Te«i<^ nndorgoiot: its normal dovelopnunt tuid pre- 
aentJog its nmnal appearanoe is diatinot proof that the lymph within it ia 
unoontaminated by foreign virus, appeani to be a correct one. In tiyphihtio 
ehi)dr«D vandss may a«nuaa this appearance, and are then incapable of 
tmnmitttin;? "ny disoaae other than tbo cow-pox. It howovL-r. iu _ 

lyiiiph fi'oiu tboM veaicloii. the puncture be mudu careicasly, and, with tb«' 
lymph, some nf tlie blooil lie tnifn up by the point of the lancei an<l inwii- 
Iat«d into a healthy chilii, syjiliihA may follow. Ko doubt many of the 
CBM'H in wliirh a sypliilitic ranb bms rol]uw»l luctriuatiou bsTO oucurrul in 
children the suLjecUi uf inhuriteil tiypluhs, iu whom the febrile mOTtuieiit 
indnofrd by the proocae of voccauabon hjis determined the o*ttbreak of on 
ahfiaily existing diaorder. Ho also in errofulous children, a httJu deraoge- 
UH>»t of the IkMdtli will oftan rouae up tlie lnt«ut cachexia, which but for 
this might have remained dormaat a little longer. 




Ownro to tliB braeftcctit diMooT^rjr of Edward Jenuer th« full t«rrorK of 
■iiaU-(M>x ui it lutfld t» pTdTiul eun now iuuniiy. be r(>aJiz^i In uovaeoi- 
BSlett perw^tiH, and tbaee. upon whom tlie ojieration lioa b«en jiprfonned iia- 
frHediy, the diBWise may still rage with b11 ittt natural Tiolence. but in or- 
dUtan' oases the form of t\>« (Maftme mot with is the milder ^iiriotv uhitih 
WMOed Tftiioloid. It ift tlko i>nm« dise^M aa variola, Althmi{;!i inodified 
mcve or leas bj oocarriit^ ia a mibject partially protected by vaccinntion. 

ijtnaU-poxUonetif tbemoHt infepliou«nf tiinHcuU>fi{)eci^c fen>n,and to 
tfau r«ajMct the randi£e<1 foru itiut (Imigcroiiniutrun vimolfl. . The pationt 
■Mms to be cspablu of coiiiiiiuaii-4LtiD<; tbv disBuae uvcn buforo the crtiplion 
■opeana, probaWjr, therefore, from the Tery begimiiDg of the early fe\-er. 
He also conliiiuee U> be u Houn-e of dnn;^ to otlier^i as long hh anv par- 
tide of scale or scab remaina attached tu liiti body after Ute eubsidcuce of 
tbe diseaae. One attaok usually protecta agaiiiBt a fl«ooiMl, but it is fai' 
from uucommoD for a person to tak« lh« feTer two or «ven thr»e timflH. 

Morbid Anaiomt/. — Aa in most of the infectious fevers, th« blood in 
fatal cnaee in dark and onaguIale« imperfectly ; fibrinous clntn are often 
IcNflld in the right TentJicli^ nf the h^'art ; mid in v*>iy Kevem m»en hwimcnv 
ringie extravaiMlionH aii? Koattf<rf«l n)>out ia the locwa timao beneath the 
aorottR ood mucous mc-tubnuivH. lutertml or^iana, audi as tits heart, liver, 
■Dd ipleen, ax« either pole, fiubbT, und soft, or deeply congrated. The 
maeoOB membnnes, «ipecislly of the air-pattfw^H, are inteiiKely hymrwiuu^ 
md are tlticketted eoftencd, and sometimes uio<-rat«>I. Tb«ir 'epithelium is 
partially anMrated, and thi.-ir niirfuce in cuvere^l with a brown tenacious 
niicus. Tm MUae combtiuu luiiy be fuund iu the inui'otiit meiubrauu of 
the aaaol Cuhmb, the mouth, faut-em, and gullet. In idl of tlietie parts small 
ezcortatiotiB may be noticed. They are small round apola on the mucous 
■nrface, either covere^l by a vhitisu false nembnuie or presenting a round 
point of sopMfleial olcemtiou. "nieee ore prnbnblr due to on empttoB oo 
the wuicoos membrane of a like nature to thiit which takes pla«e upon tfae 
diio. No such appearances are aeen umn iho t^astm-inteetinal macone 
nembnne, but tlie inteatinnl follicles and tlie glnndaof t'ejrer'H patchea ore 
Urge and prnjertinf;. Tli<! lunga ore oft^n intensely eoii(;ei<t4><l, and are 
KNBstiBca the seat of pnL-muotiiu. Moreorcr, the pleumof one side may be 
ded vttb sero-punileut fluid. 

Ia the sldn the morbi<l changeia are as follows ; A puturtifortn brper- 
Mttift takes place at vaHoue spots which extends through tho (Mitia to the 
rete macosum. Hie ctWn of tliiet pat-t swell and proliferate, so that a solid 
simply deAned no<lule in furmtfd at the intlaiiied spot. Next, tlie ejrider- 
oiis is«l »p by fluid exudntion inlx> a vesiele. Tf thifl be formod round 
a bair-fiiUicla or sweat-gland, it is uiiibilicntcxl in con^equt'nRc uf the sum- 
mit being held down by the duct The vesicla is multiloculor, for its in- 



tfrior is divided into 8©venU rliamWrs br dclieafe pnrtitionfc These nre 
tint liliriiioiiH, riH used to Iw tliouglit, hut are fnrmiKl liy compreRRinii of 
tlic alt«r<xl o<>ll8 by the eflu8e<l lliiiiL 'They tUaappeiU', as \vt]l ns tlii- um- 
liiUcuUoa, wben tliu jiroc«H.i uf lUdUimtiuii itt roiujufti!. Tbu vctuculai' tlujil 
oODtaioK iiiau}' loucocvtt^M and hoiuo reil bloixl Ly>r})UB(.'lea An U:e [irolif- 
ention of the cells of tlie rete mucosum continuett, the flnid lM>(>nniM 
Iiiinilciit and the Te«irle in rltnngMl into a pustule. TL« true aido ia soaio- 
timeH destrnved b^ this supuurntive uroc«8H to some dt^plb, and there is a 
deprPHsMl {M<niift]iQut sc&r then Mt &tt^ the fiiU of lite wab. 

Syntp(<jm». — The period of iucubation of small-pox when CODtriotcd by 
lufectioii is, nnwriling to Mr. Mm-»on, thirlffQ tiine-H twenty-four boors, 
tft, IweKe wholo '\%y* ami piirtt of two otitors. If tiio discnge i* pWHlu«?d 
by inoeulAtion. the period in ithortetiod to wvea f>t ei^t days. During 
this Btof^ Uiern arc no tqrtnptonui in onlinary rauies, idthough n certsio 
niDount of irritability nnd peevishnem in eoiQetimes noticful, not umnl with 
the child and indimliT<> of uncasineRs ; btit no <lctinite fr^ptotns can bo 
obHcrrcd. Ott \hv faurt<^H;iith thiy the first <Icuidv<i uKhcntiuu of tfaeiUneeB 
appeals and the iilat^e of luvaaoi] bqpiiB. Qiilliufst with a rise of tem- 
lierature, eirlniettti ofleu diutreflmog, and ORYen pains in the bock atid lointi, 
m)tiiftioje« ill the hmbs as veil, ore the obaructerifltic featutCfi of this 
ix-riud. The paiu iu the bark may Ik a(«octalc<1 with tempomry psro* 
utegia, and ia oft«u combined in children nitb iiiiMiitiiienoe of urine and 
fieoes Other ^nnptnms are : thirst, toss of appetite, a coated tongue, 
grinding of teeth, frontal headache, and coiiittipation or diarrhn-a. \ 
wtvero amouDt of nerrotiH dutturbance ia often »eeu, aii«1 tlie rhild may be 
tlirowQ into Tioleut and rei*Ht*d eonnilsioii» with intorniedialo dolinum 
and fitnpor. The nolcitce oud frc<|Ucuor of thcs« attacks ore not to be re- 
lied upon ni) an index of the scTenty of the Ulneas wbicli ia to follow, as 
they are prolmbly de|M^ii(lont less upon the intenidty of the variolous poiaOB 
than upon the natunil nervous 8en>*ibilify of the child. .V little j^irl. a^ed ■ 
aix Vf^am, Itcpui to hare fits on November 27th ; thiy lYmtinucd until the 
2i)th. Iletween the coH»'ul!iive tieizurea t!ie child waa dnncsy ami stupid, 
and often vomited. On Uie 2i)tli the eruption appeared. The nervoua 
nynmtoiuit tlivu ceii»«<l, and the di«.<iiae run a particidarly favourable counwb 

The jH'riod of iiiMtKiou liuttM for furty-ei^lii boiuK During all tbia 
time the initial Hvmptutns |H'niist and the temperature coutinaeH to rise. 
The pyrexia in not olw-aya great at Ihifl stage. A boy, aged eleven years^ 
a pati'eut in tliu Ilast Loudon CLilchrens' HoaintiU, snaering tvom heart 
diuaae and pleurisy, who bod not been previowuy feTerish, was found one 
inoming to have a "temperature of 101.6'. The nest morning it wm 99", 
and iu tlie evening 102°. On the following morning (the third day) the 
thenuouieter marked 102.2°, and tlie eruption appeared. In many rasw, 
however, tbfl pyi-exia is pvater, ajid the tempemluro uuiy reach lO.'i'* or 
higher. \i\ the ease of the btlle girl before refcrnd to it was lOStG" on 
the morning of the necond day. OccHsiounlly during thia stage srosecv 
loiiR eruptiiin, very like the ndi of wnrhUitiB, appeani upon the akin. 
Thiu if) luoBt ronimon in coacfl of modifl«d smoU-pox. It U right to say 
thiit tho HymptoniH of the prp-eniptivr stage arc notalwan oaen iu this 
iiiarktul firnii. l>r. Tnining of the llnmertnn Fever Hoiipital informs me 
that of the ebildnm who are iidnutte.1 into that inatitotion auflcriug from 
variola, many have complained merely of uuUutae, headache, or ttickuoas; 
luid in not a few cases ttio first symptom noticed was the rasb of the 

Tho eruptive stage begiiu) ou the thii^i d^. In exceptioual case»— 


\y tliose of amaligiuuit clmiTict«r — the rasli may nppenr on the eecouil 
dsT. OoeAnonally it doen not tihow iUoU until Uie fourth. These <ac«p- 
turns are found in all tlio cruptivo ferore. The spodAl sinaU-pox eniptiou 
iiui as small red papules »catiered more or If^ss thiddj orer tlie Kurfncc 
CT HJ* ftrst DOtionu on the chin, notw, of forehpfid, and tlicn t|iu('klj- 
~ to the whol« face. They arc next 8«i>a on tho nTist8, oud m IIki 
BOnrM of the foUovring twi'Dt_y-(oiir or forlj-tiKh't lioura uprend Rrndually 
to the (?best, the anus, Um- trunlc. snd thn lower limha. Tho spoU lu-fi not 
sprinkled irregixlarly over the aurfatMJ, but mny bo noticed to group thora- 
bpIvck in threes luid fivfs; oftcu arruii^cd iii ft BOinifirck'. Sr>inctiiuL-8 
when two of ibetut cre»ceiitji come toyetlier, ihyy mny }yy their jimcliuu 
oomiilete the cdrele. Ttie spots are net more thickly on the tacie than on 
the bodv, ami as thej app«ar eorlieat in tliis situatiou, tliey run through nil 
ir stages, a»rl scab earlier hero Uiaq on tiia truuk nud limbs. The 
ule M hnnl, and given to the fiuger the eeiuuttion of u limnll tihot em- 
ded in the sbia. All are not, bowerer, of equal firmnes!). Some have 
ach more of a ahotty charncttr than otlierA. lietn'^en the pnpulni the 
,in is of nonnftl eolour and appearance; but if tlie apotn are set very 
[cloavty together, tb«re may Ix* n general rodnosa and gmniilar look of tho 
ihca without luij iutorrontn;; uoriuul tint of the Bldn hriii;? riiiible. 

At the some time that the p:ipuleH nppenr on U]e skiti, a|)atH may be 
■bo oeen, if locked for, on tho iiidde of tiio oheeks and lips, on the inside 
of the noM, and sometimes even on Uie voujuuetiviv. At lirst, as they 
anise iittlu diiicoQifurt, these are miuruely oumpIujuiMl of; but after a day 
or two they producr*' KTili\'ntiou, and pntn iu Kwnllowing. and, if the oir- 
pHRBge* are simtLiriy niriK-t4>(), boanienosa and cough. There ia also some 
aoaffling, and the eyee are red and wal^rv. Lnter, wlien tlio raeh is a]>- 
praring on the lower limbe, the niiifoua Dienibrnne of the vag^ina, or 
oretlirB nnd ]>rcpiirMf, aIi«o become the seat of eruption. 

The cliauRCs whicli occur in the nwh are as foUowfl : The papule ©n- 
brgea^ becoming i\. fUit-foppod nodule, uid in the connie of tho second or 
third day (tifth or sixth of the diseaAo) eh.<iuges into a veHicle. This 
change takes plaoe, as lias bocn a-ii 1, earlier on the tacts than on the body 
or UrnlM; aud, indeed, while the {luipuleii are couiiu;; out on the lower 
extremities, tho?te uu the fiice are aln<ady cliauging into vehicles. The 
nmcle is broad, tiat-toppe' I, and umbilicated Its eontenta are opaque, 
•ltd at first whitish iu colour ; but by lUe ndxth day (eighth of the disease) 
hsTfl become distinctly jiuruleiit, a rlicp ird arcoIiL hiia fanned ronud the 
podc, and tho luibjav^nt ^kiii i» shMIcu by iiillaminiLtory elTuoiuu. The 

r. is now a piiHtule sentod on a lbi<rli«nod baae. From the eighth to 
eJerentli day the pihk eiilnrgt-s ; aud tho union of npighl«»iiring areohe 
and the t1ii>'kened liiisf-ti of the puMtuIett piVKhuH-x a general redneSR and 
Mt«Uing whii'>i (-omplctety obliterates all diatinptive ehiwicter in the f*at- 
mvs of the putieut, aud causes a distressing tension and smarting irrita- 
bonoftho skm which is grpntly complained of. Tlieremay be nlso extreme 
teodemess, so that the «tlight<'«t toudi is painfiiL The eyes nxv often cloned 
ky the swelling, and the Uds are glued together by the ritiutcd accretions 
tho Ueibomiiut glands ; the no«*o is stopped up ; tlio Bccrttion of 
ra is profuse : and Hwallowing is very difficult and painful The voice, 
is hoarse and the eoiigh diatressiag. Often the eyes are inllamed, 
aud very HcnsitivL- to light. Tlie proueas of maturing of the 
(sta^re of maturation) lasts from the sixth to tbe ninth day (eighth 
elerenth of the disease) on the fnc^ ; on the lower limba it begins 
eodfi a day or two later. CouMvqueutly, the vaginal and urotUrol 


■■Wa and tbe diMtrui tbey ptodoM we at tbetr htl^hi vrbco the fftociol 
aad faijii^nl macnos nK-tnlmiies htm hagan to iiuiiruTr. On them aod 
Ab edMT BucxHiB mkImm tb» «nipt)Oii dOM not pus tpeyood tbo vcsioukr 
«htPh b"* >* MooniiNUiuM] I7 ooDgidanbls Kdneee uul swdUia^ of tL« 
mmiiKaam. Wliib' Uu> puiitulta oru mftturin;; on tlie akiu, Uui Hoppiumt- 
iag ^"^ gna oat 11 peculiar aud un^eaBUUt o>lor, ivliicli ix, liowi-ver, ebar- 
iffBftM' of Uie diauMS- 

IW KUBtira litag* bwls about dgLt du}'K — from tbe tliinl to tlie 
ilsnaUi of the iUoaK. The ujpeanuic* of the rsAli i« lutuaUv tbe ngnal 
ftv a ismiKioQ in itio fever, and iu the sriupto^is of i^porml oooHtitntional 
£ateiiHDee ; Imt Uierv u wldou a notoble faU iu tliv tomi>cratuni until 
Ar ec«|i<ioB ia full; ouL If Uui pvK-iia reiuaia liii::li after thtf pspular 
-*-if- ia coutpleted, the diflBMtf ia seven- ami uuiuodili^ or saiuo cooipli* 
mCmo H icWMiDf lo roofltwut suulU-^x tbe remission is very impcrrect 
aid IriTvnrt, tho rn-lucUou of temperature is incooaideralik' : und wherena 
ia * aiU diMnte caw th» potient feela almoat well at this time, iu the 
Mine lam of the diaense the aUemtLoo to the distr««» is much less 
•aai||l4% Bad afui at liiia early stage of the illuew pholopLobin. ealiTo- 
ttMk fan ia deghititiou, and Loonie coii};h nuir be tbe ttoiuvi! of great 
ifciiWiifnil In ail ordiiiary cuse of iliui-n-tfr HiniLU-{xix tcIicii the eruptioo 
■ hHy out. the tcuipetature^ althouj;li »tiU ii1>ovo tlu> uonual level, is cotn- 
jHalivaJgr lAd* nwed ; nemius M-mptomit tire no loBgsr iiotic«d ; and 
«m^ for tba km! iueonfOtaeDoe of the state of tbe ikiii, the coudition of 
Urn iMtirti* t> greatlr inproTed. 

Vhva tbo piuftular stage is TCii«bo(l and tbe prooen of tnatoratioD bo- 
tfiaa (atkMit the idxtb dAv- of tlto nwh. t-i^htb or ninUi of the disejue), the 
taMpantoiv riiv* again, au<l wbat is c^eil " tlie secondary ferer ' begins. 
lb* iahMMitr **^ ^'^ ^"^ pjroxis yarifra according to the aevvnty of tJie 
atli^t la mild namna it maj' bo tJight or even iklNieut ; but 10 sci'ere ntaon, 
■MMttU/ iu tha ooDLflaeot fnrm of the furor, tbo tempeiatiire rises to a 
hMar bv«J. mriaaiw, tiinu in tbo ea.rUL>r stage ; the diuil is stupid or de- 
Sa<n. and oOcb wakeful nt iii^lit ; iiiii toDgiie is furred and often dry ; bis 
Miw tfihr i^aiiA and feeUo ; liis wuakneaa is great ; and tremon. subsultus 
MMtevM. vitb oliier ej'uiptoms of prostrntioa, maj- b« notirad. In not a 
lia rimi iba diaiMO baa emlcd in deiitb before the period of aeooudarj 
l^f^f ^ [jaohlii lo tbe iM'Tere cusi'^ if tbe patient do uot die at this 
Mm* hvm tha vfatkiwa of tba diaeass, be is retj apt to soocumb to an in- 

^1 *"— oomplioatloo. 

'CW aawtttUR C>*'er lastn until tlie innturatton of the pustules ts ootn- 
|A,|^| ^^ III, ■larautb or twellUi daj of the illness. The disease then en- 
CuTaOw »ta Inlitf psriod. that of desiccation and decline. In tho course 
«t b**^ W Ifcns diuv the pustules discbargt; thtir conteDta ; tbe redoess 
,^1 Tyclliiyr uf Um aktn subside ; the odor from tho child's body becomes 
mjJbwi^ WhM^'** ; •""* yellowiBh-brown. thick scabs form from caUng 
4|^7»WMIm1 wovti^'U. Nc&rl:^' at the some time— unless aoma faboile 
T|.,.. Jl:.,4.^ | MJat llr pyrexia be^ns to subside and tbe tougiu' to clean ; 
iK! .17t!rhrL^ »l^rai« eODOeetecl with tho mucoim membnuues diMappeftr hi 
Sr££|r^V^-b tht'T *>cciiiTO*l i the pulse slackens and tbe i^pelito im- 
uir^^fSe lUtUtf oi the crusts is aceompaoied by some itching of the 
^ ikea mW« sarliof in some ports thiui in otbent. and is delayed in 

K 'i> taaiMuount of ulooi-ation wbicb in present in tbe ciitU, If 

iJ •! t^ tMhlw bet'oiiie\«i7' thick and honiT, aud remain attuolu.>d 

!iH* SfaiarUaies siu-icewiivo crops of scab are tlirovni off before 
V iMtf inrtrt Ims become healthy. lbs size of the CUJeti crusts 



subject to rarieU. If Uir pustiilra hare ban tUoUj aef. the odgc-s 
(Mi{(l)lxiurii)g DOibti iiiHj unite, so thni Wga piMM of dark brou'n, 
homy crui£ b<iAnna» Aottu'hoil M.t the mmo time. The HpuBtioD of the 
Kibe is often \ery eiovr oii tbo sculp in cliildrcn ; otid often new rntsts 
oootinue to (onn iifter olil oneii bsve )wen remoreil witli wearisome persuii- 
mmcl. WbeD tlis crvKtA bavc nil fallen, tbo siirffuw in loft mottlsd witb 
ilij^tly elected red flpots, wbivh t-vvntuidly c-itbi-r diiiappeu ksvioti no 
tnoe, or. if th*TO has iMeit ulcentioa. change into depraned white dei-p 
■can witb inveitod adgM sad an iRegular floor. 

Oom^iMiioni*. —In serere cases, even if the ehUd Hturive until tb« pi- 
riod of nw aaooflilary fever, be isY^r^ upt at tbiit timu to be cairiod oflr 
bf somo <m» of tlie loftuy coaiplivaliooi wbicb ura liiiblti to come on in tbe 
tutrd or fourth week of tbe illiivtw. Tlw revert' formii of bouU^wx, espe- 
ciaUy tbe ironHiieiit Tariely, are most oouunoiilv attended hy tiwae aod- 
denle ; btit Ibfjr nmy abn follow tbe milder foruiH of tlu> diaeue. 

fioit^iiwe «eri>' freqtwnUy men; aiul tlie intense iiiflmunuLioii of tbe 
eati>i wbicb oo^iuv in the «cv«r«i- attacks miy pOM into partial mortification 
of the tinsuee. Spots of gttagrene are thua formed in the akin, and the 
«une thing uaT be observed in the genitalK. It a Bcrofulous chUd who 
mJStrs from m^iaLtiH be nttoclcGd by aninlUpox, there in great danger leet 
gaignsio of ibe ndva aupcrvcuo. Bach euen, it need nob be said, are 
*«7 dangercMui. 

AbMXMe* iukI actilfi cellulilin may ooour. Deep-aeated eoUectioas of 
nuMer oft«D fona and nuy i^jicU a* ooBsiderabk me. They are slow to 
beat Somettioea tbe jntnta are tbe aeat of siippuratiou . 

Erytipitae nnd ptfiKuim are common in 8tuaU-pux hois[)italx — less com- 
noQ in pri^'at4> hooscs, nUhoiigb t.h(>y mfty bo met vnth snywhore when the 
dfeMaae is coofluent or very severe. Tbe lattc'r of tlie two sometimes aiic 
oaeila to the former and is* very fatal. 

diiw with Buppunition in t)io middle oar in a. noi uncommon oompbe-o- 
taoQ. The resullx wbivb may follow from Hub di«tr«Mwiu{; lifllictiou are 
daaeribed elflewhcrc. 

In all bod ooaee of mnall-pos there is ronjanctivitM. which nuy come 
OB w eorlr aa tbe tiftb or sixth day of tb(! eruption. If BweUing prevents 
ibe Udt( from being opened. conjitiictivitiB may be eospected if tbe vliild 
complain of p&iu in tbv L-y<:b»1], iiicm^iMCHl by movement of tbe eye, 
•Cfi of a feelinf* of dirt boueuth tbe lid. In very taro in^tancee we 
aeot witb e. development of «tuall pustules on tbe mucouB membrane of 
the eye : bat alight ophthAlniin of iliia kind on a rale is easily overcome. 
Tha aerape inOuimAtion wbicb leads to ulcemtinu of the comes and d»- 
■tnutioa of tbe •7«ball eef« in about the bcf^innitii* of the third week (on 
Um fbartaenth dsy. aoconlin^ to ^Ir, Jlursno). An ulucr iippt-:u-s <ju the 
Biargin of the comea, KometimeH on both nides of the conieH at ibi* siuue 
time. The variouH liiypm i^u-e tjuickly penetniteJ ; the aqueous huiiiiiiur es- 
; and often the kuB and vitruouf* huctour arti <U»!har^'J. Tbe proceoe 
gaoonUly vorv r^id. and may be sccotnpuiiif^d by no pain ta tbo child, 
es, instead of ulceration, fj^neml slougliing of tbe eyeball may occur. 

To some form of che«t affeclton mtuxy deaths in small-poz are owing; 
Tlfiuriay is common and rcry fatAl. Pneumonia may begin inaidioualy. 
aud is aliio a Terj* serious <.<omplicstiou. BrouuliitJM is somi^'timus a vauM 
of death ; and, according to Riiliet and Beuthez, puimtmanr' uKlema ia ooea- 
■ionally met witli. IV^sidee tlu^u>, {xin- suil enuo-corditia may auperrenc, 
■ad it te «tat«4l ou tlte authority of Di!KI10S and HueliArd that acute taity 
a of the walls of tbe heart may be a cause of suddim deiitb. 


m!t£A$K IX CIIII.DRK?:. 


llie lurnfreftl symptums iluring the pcxiod ol w wAit I«w i 
complicated br o^emii of Die larmx. Ttaa, bovmc; ■ wMa 
Bxcept ia c— w of rouAuent aauU-pox. In olfaer inriMMM ■ Hvote hi^n- 
uitia tnaj be set Dp, loHline lo ukentiaii of ibimodb mm^tnuB, periofaoo- 

drttb^ Aod neerosis o( cartukga with oouiecitwiit efaratie ■j**— '■ 1^170- 
f^Ua may be ooe of the earliest eomplicatioDfi, mi m iwelaiiLe mco on tbe 

titDtb or el«Teoth da;. 

Id tbe on ofaDf of tbeee compUcatkitis tbe ferarislugb mod tbe child, 
will) is bwdjr eDtoring Qpom oonTweeoence after ea esbeartiae ilinrMH. ie 
ta » elate of great wealcncni, which ie inaUuitlj aggrvnieA hy ue preaence 
of the intarcurrant leuon. So thai, if tbe {latiesil do DOt BuecmBb to tZds 
Dew danger, hU iUneaa is B^ioualy protxaeted and contelieBWioi' piopor- 
tionalaly delated. 

yariaiea. — Maa,v nirioties oi noall-pox baTe been deaoibed ; bat lor 
nnv^eal porpoann it nill be snflieient to remember tbe ^eeial foriDS of 
bimrn^te, Coiillitcut, nod Maltgnaot eituill-pox. aad the laodoed fono foimd 
ii) (Ult-ir-iitly v(U!ciB»UKl peraoos which is called varioloid. 

In tlir- tlut-refe \&ri^tv tbe e]K>t8 are wpaiated from oom aoother hy 
lidUlby nkiu of normal tint Tlie ^neial symptonks are aaoalfy milder. 
u>d tite favor lees 3iigb, esperiHlly the aeeondanr pjrexiai which ie macb 
leea Ktvoro. Still, eren io uitit form Heriouii oomplicalaooe m^ atwe. uul 
wbeD dcAtb oi^nin, it ia uauallf owing — unless the patient be a joong tn- 
fniil — to oao of tlicee wcondaty Icetoua. 

1'lui coiijUteixl form ia attundecl by n vpiy high mortality. Trtmx 
tlin ri!iv>ril4 of the lioncKm Fever Hospital it nppotra that of thos« at^ 
InrkiKl by this vnriftly fifty per cent die. In children probably the 
proii^rtinn i>f doalJin wtiuld lie miivb |^-ittcr. The danger coDsifftB Dot 
only III Ibti aoverily of tlie eniptiuu. but alitii in tbe intensityaf the genetal 
eyiiiptoiiiH- 'IliK initial fercr is rery violent, and ia often aeeompatued bj 
liilfb ilnliriiim : Utiire in little reiuiesion iu the pyrexia when the dctrehyp- 
mvnl. of liin i-emIi m (<niiipl>'tftl ; trcnioni and signs of profsund narroas &• 
prt>Mfli(>Ti 'Mllll^ oit (firly ; \\w tiUi-lliiig auil iiiflatunintton of the mnoons 
muniliraiins jim«liiM' jtrtiit «!ii(ti«s8 ; and th* seoomlarr fercr is Te«y tio- 
leuL If lliii rliild nurrivt; ti» tlio tliird week, which rarely happeoB. a aeri- 
oUH iHiiiiplimtlon luninlly oooors, luid this in his exhausted state provee 
repiitly (ntjil. 

'riii-«i> tiiMMi, on nccoiiui of thoir WYcrity iukI fataUt>' io young subjertSt 
lliluM liii iuslly ib*(TibB*.l ns luiUigiuuit. Tbe terra ia. bowever, osnally 

Kiihlhii'il I nM'ii III which the oer»ou» Hj-mptoms are oremrbelming, and 

IliK i>bllil illiiH nipidly from bloo<I-iM>ii(ouiii^' in a stfit« of profuuod depieo- 
eliMl iiml t'oiiiFi ; iir Ici t'asra wbere tlit- disease iiasutui.'s u hiiinorrhii^ie 
ii|iKmi<(i'i', III Ibii Itii'morrhn^o fonn bleeding oofun from &I1 tbemooooi 
imeiribniiicii tl«f ikim-. llu' iiioulb. tbo ftil-piww^ee, end the bowels. ILe 
III I (I'll nitli liUxxl ; tboeruptioii isdnrk.niidmLxed iipwilH 

I„ i. I . I kitilM-iiliiiuHxiiii'struvaaatiana : imd tbe fluid iu tLi>Tesicles 

■ IliiMi'.l Mlili'i>d. Tbug«D«nil sywptomB are ntvere. the proetnUiOD 
If„...i .....1 .UiaIIi ttikoe ]Jsoa aflor n fvw dsya. 3Jy frieml. Ih, IVining 
),„ I ,| iniiin II vni-iely <>(thn fiialiifnimt form of tuiisll poi wbieh has 

t,|t ItT bin n«'li«'r 111 tlK' Homcrtnii Fever HoBpilul Iu this the 

iilillil iiiiMiuini M«i>rMliiOiiiK>l by Uiv violoora of the disease. He Uee to a 
Hliilf "f dliiptu'. immI bHM no 'tnw varioloas nuth nor any of the ordinal? 

Mviui N ..I tbti illlH'ti*. Ou iiwpoftion of Ibe skin a iiuiol»'r of decfi 

I i I'. ' i . . -.-4III. Tlieoe are irell defined, and are more 

oze from a rape to a miHet seed. 




toA are twentr or thirty: in number. Mix«<l uj> with llietn are laiiger 
fttcbes of Bubcutnnooiui (txtmi,-tutntioD, like bruisoeL Theae patients lukve 
. renr ofleitBive sucU, ok if putrefaction bad liegim before deatli, and snr- 
Stre mt a few hours. 

Farif^id, tbo modified form of the clisesM, ifl osuiLlly a mild Dom- 
pbunL The early e^'mptome arc the ennic as in triio BmAll-pox. and may 
erao be of hoiui.' M-verily. A cliild miiv liiivc lii^U towr. much jinin in 
bnck. rvpeiitt!!.! ruiuitllig, !U1<1 lx> ouuvulH«d ; but lliv after-nnunw of 
diiwuso is uHiiflUy boni^i, and iu piirticuLir the it&cAndary fever is ftUght 
ipli!t<ly iibet'iil. Often, the mah is pri^t^eded by» rOMuluus cniptioii. 
(proper nwh of varioloid, which co)ia«» out at tlie usiu] lime, is iu mutit 
MHea oompurstively thinlj wnttorad ov«i- tlto 8ur(»c«, and the syois are 
verr rmrely e«t aiiffictoatl.v clowly to be coiifluoDt, even oa the bice. Aa iu 
«'uiotn, tlin iiiiicouH membranes ore nifected ; ami aolivntion, diWciilt dt>j;1ii- 
titi<H], suitiUiug, boA.i-st>ne«a. aod miigh ai^e (•ommoii ftjniiptoms. Th« HpoUt 
rou throuf^ their staffs more quickly thnn in tlio unmoiUflod form, ood 
the stage of desiccotitm tiMUaUy bcpiis on the fifth or mxtli day of the cntp- 
Ftinii. The stage of mitlunitiuD in also leasaeTere; thei*n is less Hvrplling 
•I r^lnom of the Bkin ; and pyrexia is Hlipbt or absflnt (ienenilly the 
)aistiilt.'H, toateud of rupturiug uiid Jidchai^ii;; thmir contouts, dr;,' up, so 
it the pock gnulmdly rhant^tt into a tliia brown scab, wliich fuUa olf iu n 
sw days, 'rhere it* besidtH little or no ulceration of the skin, and couse- 
'qti<-iil1y no pitttog is left nfter the subsidence of the diseoiM, except here 
and tliert- where tbe inflammation had pr<»oeedcd farther tlianusuaL ijasUy, 
in riLnoUiid oompli cat ions are rare, and Uie disease is usually at an end in 
B (ortnif^ltt. 

Vioffnoeu. — Before the emptlon appears the dia;^oas of 8maU-|K>x is 
Alfllealt in children, for fever and Tomitini^ UHher in many of their ncutt* 
disnuw^ niid pain in the bock is not always comjiliLined of. In youu^ 
ebildn-u the AXist<'nc!e of tlic spinal pain csn iH^liom lie ascertained ; but if 
a child, in addition to Tomitiu^ and fovcr. loses control over his sphincters, 
we may suspect small-pox. for such incoDtinenoe is not a common nymplom, 
and points to some oj^cdal condition not present at the onset of an onlioBir 
acute iUncia Iu suiall-pox it oiay be th« consequence of the spinal irri- 

When the eruptiou fin;t appeal's ou tlio facu it w uft«i] mistaken for 
Dieaales. The colour is very simihtr ; and the wu'ly papule* miiy bu easily 
oonfbiuided n-ith that form of measles rash iu wliicti the spots are more 
ifaan il«ia]l> elevnteil above the surface. On closer inspectiou. hovrever, 
diftoranees will he nnlici^d. Thn nu-o.'ilrat spot is much less raised than the 
imaUrfiox pitpulc. mid is not Imrd ami r^sisLiu*; to tlio finger. Moreover, 
in meaaleB the cou^li. coiy;rji. and Inclirymtktiou arc »i->nificimt symptoms. 
and are quite akwnt in tiif- early pei-iod of variola. Tlit- tempemture, too, 
b 1ms elevated in m«wter» during' ihf- sta^'f of invasion tljiui in small-pox. 
la mmslex it is nsunlly between 10)i.'>' and UH'^, whilo in variola it is often 
b«tw(!«n 105° and llMl^. After a day or two the chauf^o of the papule into 
a vesicle removes any doubta that may have been entertained as to tlie 
onlure of the illaesa. 

The roseotons rash which sometimea precedes the papular eruptiou 
nt^ bo mistaken for scarlatina. It is d isti ii^^iislicd from it by noting its 
Ina complete dilTiision over the surf.v'*-, its bris,'ht<T tint, and more mottled 
dararter. Moi-onver. orconlinR to >t. Sec. in rases of small i>o\, when tlie 
rcHBokma eruption is premol, the variolous pnpule Uas already begun to 
r, ood may b« disooverad by careful examination. 



Tlio remisaioo of tiie fevAr, which often tnkvtt place irhcu ih 
eruptioD in completed, eaomt be rehtnl upon for diAf^inosU. an 
uncertain. In tbe boy whoae one was n^ft^rretl to at Uie beglaaing of 
thia clin|>t«r there Wfts no reuiaaioa of the fever at th« early penod of tha 
trruptive »tage. On the oontmry. tJie t^mpemtum rone etill higher, nntl 
when the paUeDt mut sont »vnky to the nuall-pox hosjiital on the third dsy 
of the ms^ the spot« boing then TOsienLvr, his t^tnpCTVtnre (ak 8 k.iL) wna 
101 4^ 

Varicella niAj Iw rpAdily mistaken ffir moclitiMl Htnall-iiox. The <liffer- 
tmCMl>«twopn lh« twn clinMuu^u nro df-iM'nlMH] elaewhereL 

Pro'jiuigin. — Tbo mortiility from HmuU-pox in childhood is very hi^h up 
to tbr n^ of ten yearn. lufiintH nmtnDy nuccuinh to tbe diacuknc e^rn in 
the diRcrete form. The previoua henltb of the child is no important item 
eetinmtiDg bii «hui«es of ncowry, for weakly clultlren bdve small _ 
Btof poesiae^ safely throa{)4) so fonni<Uble a trial. Little information' 
can be gaiu»1 from thu w^vrrity of the initiail atago, for violent convrikionii 
may nsliAr in n lM<uigu form of tbe thftease^ Kemiiision of the fover and 
conatitulioiud Hymptoms at tbe b^rinning of the eniptive sfat^e, acant 
of Uic rash. DOniiol deTelopment nf the ttpnta, and abiwnce of aubcutaDGOm 
" aorrfaagwfl^ are faTourable Kyniplnins ; but ereo in thf>$» vum a sertooB 
9iliplioatioo may ariae dnrinff the third atA(:;e nod carry off tlte patiODt. 

Of apedol eyuptom^ profosi-neMi of mliTutirm in not on unfaToural 
sign, althongh it occaaiona much disoomforL Mr, Marson ewii regardait 
a«of nuspiciouBomen, eapecially if »on»lrtned with mach awellingof tUefaea 
and niiu-ktxl tcadomvna of tbe akin. BW-diug fi-uin a luucoua •urfaoa, ~~ 
limited to one tnic-t of ihut mcmbnuie, is nut, iict'onlitii' to Dr. CoBie, tol 
Tievetl u-ith apprelmnKion ; but if more than uue tract is a aource 
htrmorrhafte, the prognosis ia very unfavourable. H.tiaaturia iB not 
sarily ilaogeroiis; but beuorrlinge into tlie akin, if anything more tliao tt\ 
lew xcnttered petechi»i can be seen, is of Tery aerioua import 

Deatnictive ulceration of tbt> eyes may be expwt«l in caflea of the con- 
fluent form of the diaeaso when the aecoDdaiT fever in bi^b and tbe skin 
ia Tery bot and dry. If, in mirh n caae. t>he eyee do not sufler. some other 
■erioua oomphcatian in eertatn to oeenr, luvording to Mr. AlanoD. Th« 
same authority aasortH that if im ulcer bo found at tht- uumo time oo 
side of tho comDa. that eye will be entirely destroyed. 

Treatm^nl.^ln varioloid and the milder cattee of dierrete nnall-pox the 
child merely requirtHi to bo kept in bed in a large well-Tentilated room, 
and to be fed with hucIi articlc-H of diet us are mutjible to bin age and do- 
^'Te« of j^rrexia While the ferer ia bigh, he sliould take nothing but mill 
and broth ; but when the p\Texia BahndcH, be may take fish or once cooked 
meat, light puddings, etc. Hia whole body itboitid bo sponged daily with 
tepid waUr.and if there in much heal of skin, tliiaprwicsa maybe re{>«ated 
aeTeml times in the twenty-f<.<ui- hours. He may bo allowed to dhuk fkeelj'j 
of pure cold water, and liii* l>€d and body Uoen ahoold be changed erety 
thiy. No medicine will Ix- rerpiired nnleea oonatipatioD lie prenent« when 
a modomte dnee of eoator-oil is indurated. As in aearlntina. the room 
eboaUl be c]««red of all carpets, ruga, curtains, and other woollen fabrics 
not obsolntelT indtmenaable. Open wintlowa, wbaterer be tbe eoMOti of 
the year, are inriiitea on by Dr. CoDie. 

Tbe eeveiwr forma of the diKenM>, and eiqieeially the eonflaent -nuic 
re<)uj(« rosy careful tixiatment. Tlic diet abuuld be liberal, given iu 
form iiH the child can digeat, and in quantity Huitnhle to hia power nf a^ 
eiiidlaliou. Milk, Btrong beef-te(^ eescnce of mest> ^Ika of eggs, light 



■of I 

thMngn, and j<>lly can be given fretjitoDti; and in bhibII qu&ntitiMi at a 
iuoe. Stimuliuita, toch as bnuiJy (Ui<l tbe bnody-iiDil-cKfr mixture, will 
■teo be tMc<i«<l wfavn? rer aigna of fitilitre of strength are olmcrrcd. It in 
best, hovraver, to withLoltl stimiilnnts during the earlier period oS the ill- 
ntm^ vnleaB tbej rta imp<>nitivelT required, for they will certainly be 
««ated aX ihe ena of the »e<-oud or begiiinuig of ttie third week, when coid' 
{ilicatiiMU genemUr apitenr. 

U the patient Iw r<'Atle«s! at night ami wakeful, a little* clilonKlinv way 
In given cButiooaly . but w« tuiist be careful in ^nut; Darcotic«, pArtJy oa 
■cooont of Um> Mmly Hepreaaed coDdition of tJi« patit^nt, partly becatue 
tin airjiawngoi beoMne readily choked by the ahnndiuit mucovs and Mli- 

Tlw treatment of the akin omptioii is ou importut caatt«r; tor in 
aouU-pox, unlike the other eni]itiTe feren, the dermatitiH which accompa- 
aSm Um matiiRilion nf tbe nuirtulaa may produue severe loisl injnry aa wcU 
as markt^l cuDntit^ilioiiiil diatnrlMtfioa. Very many different netlioda hara 
been recomm«iiJ«d and adopt«d lor checking tho nkstrativc procens and 
p«Tentiug pittiug of iheskin ; but none of tbeaeeaa beanid tu l^e »iucee«B<- 
(oL Th« af^Eieatioit of aalrea of varioiM kiad* l^jpcor t« be useful, bat 
nttwr thrriu>^ the oil or fiit tliej contain thnti through tbe obemtcal ingre- 
dient which ma aoppoeed to give tbenitlu-ir i-nlw. Dr. CoUi» pniuonncira 
agunst dMnering the natiml t>y eflTorlA in Ihi^ directioo, wlitch ore cer- 
tain to prove inemctwu, and merely rfioommcnfb* tlie use of oiive-oil to 
tlH* Rkin. A thirtieth pari of oarholic acid ini't'enw^ the thIiw of UiIh appli- 
ml6aa. Oemtan writes epeak highly of <\))d oouipresaes to tbe (aoo nnd 
lMnd^ and to any other jwrt irtiere the ciruptioD la copious. Tbey suIa 
thnt the application dtminiahctt pain, heat, and rednesa, and contributes 
greatly to tUe cumfort of thR patient 

Tbo Aore llirnat ist \x»t ti-ftatotI by bftrley-wntj^r and otJier mneilnginous 
djmka. A dinuj^hi ountainiuK fwrehluride of iron tuul glyccriue. tokvu 
thre« timen u iluy, is ufleri of senHiw. 

At the end of the stHwiid iveelc we must be on the watch for complico- 
tiona, Lturyugitifl is ofteu the fir&t to uppeiu:, and indeed this ioterourreut 
diaonier luay begin as early as tbe tentn day. When this oonmUoattmi oo- 
eora, tba room miHt be kept warm (a temiwratnTe of 70° iasofflcuiit) ; the 
eot mtut be tnirrounded with mi atmosphc^ of steam from uome on« of tha 
maoT apparatus onnstniotM fm* this purpose ; ami the tbront Khnidd bo 
MirelcH)ed in bat lintieed-meal poultdcea. Stimulants must lie given us 
■earn cUeiralite. If signs of RufilKiation are notioed, truchootomy should be 
]Mifonn«d at once. In caws of uxli-oiiL of the f^lottiii, whtro Ufv in in the 
grcktMt danger, and immediutt.- measares hate to be taken to avert n fntAl 
ianie, muob benefit may be derived fmni rnpid veairaition. This i» best 
done by means of boiliug water. Dr. Owen Kecs directs tltat the corner 
fit a towel should he Hoiiki-d in in-atcr am thi» boils on tlte tire, so as to ac- 
,ail« tbe full temperature, and that it iiliould be then applieil rapidly to 

legion of the throat Before doing so, the Hurroanding jwurts which it 
ia not wtsbed to libster must he covered vritb tbick cloths. 

Dinirhu-ii, if it be troubleaonie, must be treated with a stuaU doso of 
AHtor-oil, followed up, if necevKory, by a draught eontaioing dilute sul- 
phuric acid and a drop or two of tincture of opium. Ad enemn of starch 
-with five or ten drops of laudanum ia alao unefid. If the diBirhwa reeiBt 
thia treatment and Iwoomo oshausting, nitrate of ralver or gaUic acid and 
«pnuB SDiul bo reported to. 

The Tarious forms of chest ofiootion muni be txeuted upon gcuoral prin* 



dplea. Tbd7 are exoesstTelj (Ungeroua. As the pati«nt is usuallr hy tlus 
time in & state of great exhaiwtioD, stimubuita miuit l>e gireo libenUly : an^ 
strong lippf-ftJUM'ilPO »U{1 ollior forois of focxl rontAiumg i»urIi uoiuisluncnt 
in «mtill bulk must b« adminititeird in sninll qtiantitioK nt a time. 

If au ulcer Appear upon the cornea, it sbauld \mi tuuched ^^itb a ftolution 
of nitmteof tdlver (gr. the ounce), oud nfterKaTdittM>meolive.oU(ilic>iiIi3 
br (Iroppeii into t])e eye A Itlitrter to the t«uiple is also of w^rriee. The 
coDJuuctivilis mnv bu treated iu iml<l cASOS liy k eolutioii of xulpUate of ztuc 
{t^. Uj. to the ounce), dropped iuto tlw eye uuce or four tiinfs a <lay ; or a 
^flnlution of the uilnitt^' of lalvDr (^r. j. to the ounce) mav be uned. If tli« case 
WW severe, with mticli muco-purul^at disobarge, Mr. Mnkuna rcconunnKls 
tJie strijuger »jlutiuu nt the tiitralo lo be dropjH'd iiiUi dm vyc imce a day. 
Xlie lidti may be pn>v6iil«}d from adhering h\ battiiLg frequently nitli wnnn 
water, ancl then plftuiug a ilnp of catrtor-oil betwevn thtiu. 

Abscestea must be opened early. Xn\ agn ot mi]^)piiratioD Lb a aiguid 
for tttiiiiulauts. and for quinine willi or without iierchlorule of iron. 

If b»'iuorrliage o«cur, the patiout must bt> kcjit jierfectly qoiett and etim- 
olante must he given as required. 

In nil caaeti where tba akiu ernptiott is proAiae, cleaDliaeM is of the ut- 
motit inijuirlanca Dr. Collie (wpedally i^recta the remova) ofallcnwts 
about the nostril!) and hpa as they form, for they poison the air as it onfers 
the body of the pattout, He abio insstH upon the early renja%-nl of all 
scabs under wliiob iiuh in forming, and rpcnmmendfi that the patient be 
Ibathetl daily in a bath ni«<lic>ited n-irJi carbolic nriiL He altw points out 
' the uaceasity of frv^iuoiit cliim(;iug of tht- body hticii. If, ua ufti-n liappeuK, 
the cliild'e bend is »luw in rucovering. tho itrabH must bo n-iuuvcd by pout 
ticing, and ziuo ointment must be applied, or tbe following ; 

3* Liq. plumbi subaoetatis 3 j* 

Zinci oxydi 31- 

TnMlino , |ii 


CSod-lirer oil and iron are alao indicated. 

In the itjalt;rntitit fonu of the disease no treatment is soocessfol, and the 
parent invarinbly dies. 



KowQ^ or Parotiditis, is ODe of the mililcr infectioas dutorders of child- 
bcio<L It in rare in iulnDcy, Hiid cannot lie said to he. toiitiuoD before tho 
bmrth or fifth year. Agnin, nft^r puhcrty Ui<^ Utthility to the diaonse di- 
miniahcs. It »oUlom occutu a iwooud tiiiif^ iu the houu subject. MiiinpH 
i» usuallr epidfuiic, and ia eHpedally coiumun in the icpring of Uifi venr. 
Its tnfei^tioiuiiieiM ui fxtrenio. hu (Uut if the complaint break nut in u 
>l. or other iuutituliou wLere young i)eople are coDf^refrattid toj^ctber, 
tikvly to vK-opv. The rirus is RiijijHKteil to bo con%i!ypd in the 
The <lunition of the illuesH is fi-oiu a wt-ok to t«n, twelvp, or fbur- 
dara. There in, besides, n period of iuoubiition which luw heen 
ionalj «stiiiuit«d at from one to thive wf^ks. 

Horhvi Attatomij. — Th« disorder cousi-stHiu an iiiflttnunatiou of tlieduGtii 
<A the parotid and other hrHvutv glauda with Lufiltni-lioD of the celluhw 
tMoe <n the glauihi. Gxwtatton also invadeH the suhcultuieous tissue for 
I distance arouud. so tlutt very widc8|)read swelling iniiy b*^ the cou- 
Thc dissMsed action ■1ih:<k not (^ on to HuppurHtiou, but l«r- 
it«« in resolution in the course of n few days. 

Symptomj-. — ^Aftfr a jirriod of inrnhalion which, according -to Dr. 

DolCM^ TkrifiH fmiu 8i]it«H!n totnt-nly-tlvcdayR, thr enrlietit HijirTiHof thn dix- 

OTtler are noticed. Th<* first «ynii>tom is fovpr, wliieh iisiifUly prowdflw liy 

aimie hcmiK any eiaa of local discomfort. The tempomtiire is pfuonilly 

lu|[h, rhang eometinieB to lOtI", and, ait in often the aise with children, the 

pgrresiB is apt to bo iwcompnnied by liendanho and vomitinp. Swelling of 

toe parotid gland may occur ut tho kuiuc tunc eih the f«vor. or may evou 

precede it In any cose attention is itoon nttnicted to tim fuco. Aching 

and tluMleni«» are complained of. situated inimedialelj below the ear, 

ud behind Iheawoending nunaa of the jawbone; and on inHpection tlje 

aotmal d«preteion between the fiu.% and the neck is found to hare <li8a|)- 

ptrtd. lite awelliug 8bri]c«e forward into the fitce. and biic-kward and 

oowBward into the neclc, so that \rhen ftUly developed it covers the whole of 

Qikpirotid region. If, rut often Impj^-nn, the iudattimation extends to tlic 

■ibffltudUary (.rlaiiila, and ntt-Hclcs lioth m\e», the fnmiliar fn<>e in nirioutily 

diaSgtuvd, mid i» scarcely recognizable by the friend*!, It iu eiioniioualy 

widniod at the le^'el of the nose and lip, and the chin may ahnost di»- 

^ipesr in the nwelling of the necJi. Tlie swelling t.s very tense and eliuitic, 

■od is extremely spnaitiTo to prcxsure. The skin over it in either palo or 

is floffhsed with* A rosy-red bWh. The full ilevelo]>montof tbc 8w«11ii)g 

oeeaptM from thnni to six daj's ; then, after rcmaintng unaltered for one 

or two ds^'B loDgLT. it beginit to Ruh»ide, and by the tenth or twelfth day 

bota the IjCginnins of the disorder all fidnewi ha.t disappeared. I>uring 

tbe whole of this time tbe aching continue,-*, and ia gri-utly intensified by 

aarement of the jaw; to that mastication liLtxtmea impo<i.>dbU', speech is 





liAtuper«(l, and even swAllowiiif; is difficult and )>iimfuL Oiie consequence 
of tliui is that aalivB tcntlfi to uoctuaulato in the ruouUi, aud is a cmuse of 
iiiucli diKcomfni-t. Fortuimtel}-, howerer, its swretion in Heldom gna.%u 
tluin nntuml 

^Miile tiio (Usuusc is iu program Uie fever reiuftins bi^^b. VC\iea the 
swelling has ri^ochod it« full doTclopmeat, the l(>mp4.-nitur<> falls, uidjeuly 
or irntiliuUly, aud duriii^ the procosN of reiiulutitiii Uie beat of Uie IxMlr in 
uatuntL The disease seldom lUtaiJu the two aides of the t&ce quite tn- 
multauMmidy. Oue side gcoerall; precedes the other bv sotuc huun co: 
da>K. In rare ciiKeit tbe Jitllaninuitiop reniftiua limited to the gUud first 

Although the parotid glands are pnniaril,y and prinripfdlv affected io 
tho large lunjoritr of case*, thin iti not Hie invariaMe rule. 8ouiQtimo8 the 
JTiflaniuisitioii is locali/od in tlto subniikxiltaiy glaudg, ntid tho [MrotiJs soffer 
litUe if at olL Dr. Peuzoldt, of £!riaiigeil, in as epidemic of undoii]»te>l 
niiinij)i4 ni-i'Tin'iiig in tlint town, note«l Houie mspB in which tlie owelliDg of 
tho pfimtids niut Ko »dif^iit an to he »eanM>lv olxserx'nble, wliiki the »ub- 
uaxillaj-}' glands vrunt eonsiderahlr enhu^iwl ami rerj jMunful. In one 
case there was iu addition sv-clUng and rpdnetw of tho Uiuinlii. 

One of the nwBt curinns features of thin disorder mnsiitt in the 
tMM '«bi'<h occaaionally oocur. As the inflammation subsides, or eren 
day or two after the nwelliuf; has disappeared, a ainular coadiliou dovelopa 
itself in a distant part — the testicle, iu the caw of a boy : the hreaet. if the 
patient be a girl. Tbeee uomplicat iumi are ucoonipauied 1>y fever and gen- 
eral poorlineas, but subaido in the couri^e of a few <lay& In rare 
orohitia has been known to |irec«Ie tlio affection of the parotid g 
Thus, a young gentleman dejHTih«d to me how he luul had an nttnck of 
orchitis, aeeotnpanied by sevore pain but n nonnal temncratun-. At this 
time f.lierfi was idisolntply no symptom <^onnocted nilh tht (nte. Sixteen 
liount a.(lerwiti"dR, however, Hli|t[bt Bwelling and tendeniesw of the iinrotid 
gissd began to be uotieed, anil tJio tempemtm-e wnn found (o lie l()0.t>^ 
As the uHunps subsidett the eccoiid testicle bccuiuc iudamvd. In this 
attuck the tcmpomturL- rose to 105^. and for some Any* was ns higl 
nti 104°, with delirium am) distressiiiif i-ouii1ing. Someliues the appoi 
anve of svreUing in the oilcan aec-ondahly attacked is preceded by itcvert' 
con^litutioual symptoms. There may b« high fever acid delirium : or 
l^reat proHlmtion with culdueM^ of the extremities ; or violent \*oiuitinK and 
purginj'. In any ease, (jreat alarm is eicited by the condition of the suf- 
lereri but all apprebenHionH ore remoretl by the ap|>earance of the local' 
lesion. These rjoinpliimtion.4 are lesn comnimi in cbuiirPD than in adults 
who euffsT from ninm)ja, but it is well to rcmembt^r that it is possible tli^ 
may oooor. 

There ia another and orciuiiounl aftcr-conttct|uenc« of mumits whicli tt 
ta imitortant to be at^tjualnted with. Thin is Oeiifnesii, coming on aom* 
time after the paroti<Iiti!< luu* Buliaitlpd. The hearing may be affected in' 
uDo of two wuyH. Au uxlviuiiou of the inflammation niay taku place to the 
Eontacbiau tube and middle tur. Thesa cases are xary ameuuble to treat- 
ment ond usually recover, niere is, howei-er, another class of nases of a 
mnch more serious character, to which attentioD has been directed by Sir. 
Djtlby. Li ilicee the deafness oomes on quite suddenly. Tlie child ■;ol>s 
to bed with his hearing perfect; in the morning he is found to be deaf. 
Little can be done for thia form of deafness. It ia jMrobably dei)endciit 
upon some altered condition of the auditon,- nerve, for no appreciabir li-sion 
can be detdoted iu the aiiditoi^- ap]>aratu)i. \\*hcither tlie loss of bearing 



eotni^ete or merel;,' pftrtiiU. little hope of niAt^rinJ improvement gilh 
1m «ulertaiDeil. 

In somo rare cases na attack of uiuiiiim baa boeD known to be acoom- 
pAitiMl hy laei&i ptmlyti» from oxteiuiim of the iufiamnrntion to tli6 Portio 

IHa'juofia. — Mumpfi can only l>e mnroiiiifled wil^ iiifliiiiiinalion of Uio 
paiotiil j;lftn4 of n nnii-si«^cilic i'liar«fl<?r. mucIi m* may occur in Uie coiutm' 
of some fftvors - syniiitomatitt jifiroLkliltA, iw it has btern iiaUwl, or parotiil 
iMtbo. Id this *ywc liotli sul.^ of tlio £«ce vuay be atlndjotl, but tbo ftict of 
the lemon bi-iiip n ts«CLUnIitry, and not a priuiarr diwase, nnd of tlir nipiil 
■nppiirntion wliicb talivn place wben tlie indnnimfttion is iii,'niptoni»tic, 
fllioalil clcAT up uiiy uuc-erlaiuty wliicb miglit bo felt lu to tJie OAture of 

SIuiupH is probii'ily iuf«cUouH from lb© very be(jiuuiiiH of the disorder, 
and remaiiis su for sohip tiuio afl^r tlie swelling haa subudtH]. Dr. Squu-6 
ia of opistoQ that for at least two week^ after tlie diB«ase baa cleared a«'ay, 
the <!hitd HliouJd not be allowe<l to I'eturii to his bealtby companions. 

7Vmfm«'n/.— Ah the disease cannot b« arr«tttt*(l, but mimt run itscoiinte, 
little active treatmont la r»quiroJ. It is boet to put tli« child to bed, nod 
tji keep liim tJiei'^ oe 1du<; UH tlie tein]Miratin'e ih eleTa.Le<l. Hot ix)ii]t!<'es 
■boiilu be apjilied to tbe parotid region and Im' frRi{iifititly cbariged. If the 
pain be not rr-IicviKl by tliis nieiinK, an ointment cunijxi^ed of vqual {uirl^ 
of extract of bvUiidouuu tiud glycerine Juuy bo tsmoiu'od geaUy ujKin the 
akin orer ttiu iiifliuuL-d •{liuidH. luid tbr piiittire bo Applied as before, Tde 
jaaK must be kept at rest, and no Holtd food mii be idlnn-cd. inttteatl, tbe 
child iibould haTe etronff beef-teo or gravy (Wiiip, io<?!it jr^lly, inillt, yolks of 
cgjgSi eta ; but if tfaere l>e bit^li fever, vritli foul ton^ic uud drniu^ement 
of the digestive orgaii?i, rnt m mu«t UHually tbe cane, tUe stomach must not 
be overloadwl even with liquid food, and core ahould be token to aaj^ly 
noahsluneot in iimall quantities at a time. If Uio fuvur be bigh and otuae 
frtltamtiM, the aurface of the body cjui be xpouged witli tepid water. 
"Oie bowob must be atteitdeil to and coustiputiuii relieved by twuie gentle 
9oenaoXt snob as compoxuid litjuorioe powder or the liquid extract of 
rbaniDUfl fnui;];ula. 

In oanea of metastaiuA to the ninmnui or t«sticle, perfect rest must Iw 
anCoroed ; oiwl tlie lof>al treatment recoi»m(>nded for tlie foeo stioiild be 
bad reoonreo to. The uUruiin^ m-mptonis which sometimea precede the 
■IHWarance of tbe Kecoiid[ir>' Icmod usually pass awny iu the eourse of a 
Um boiira. If there be \ixerA proHti-atiou, Htiuiulauta luust be given, and 
wanntb be applied to tbe extremiiiea 

ciiArTEu vm. 

(Epidemlo oerebto-sfiiniU meuLiifritlB.) 

Oebebs(>-«pc<al fever in a specific inflammation of the memliraoeB covo 
ing the brain and roril. The ttmlaciv is no mere local dianrder, but a 
blood diwiuie, of wlitcli the iDfliunnintory afToctitin of tlin meningeK is UiQ 
ftoatomiotil expreseioa. it ueiuillr preTftiU in opidf>mi(>8, nnd ^utbraak8> 
of the disPAse hare been noted iii ruriuiui countries Vi-idoiv dilfcring ia< 
climatic and otlmr cnnditionH. 

li3uicati'iii.—'Vh(> epidemicH of cer^bru-spina] fer^r generollT ocmir dur- 
iim iLv winter uiouUi8 ; but isolatetl uases tare oft^n. noticed for ioiua time 
befui-i> Lli<> (UM(>aM becomes more gftuemlly diffused. Thua. bi-fore ibe epi- 
demic- wbicli pruviiilvd ill In-liuid lu 1867, Hporadic eosos Imd b«4>n observed 
in tlie oountrv for some years. The disease ajwenre to be mildly UifectiouB. i 
It fiinteos iipon old and youny, rich and poor, lint ntnJes appear to he morft> 
liiiblo to suffer fi-oiu it tlmii females. In 18-K> ftnnie cHsei* orciirred in the 
Dublin and liray 'NVorklionsos, luii) shortly oflorwnrde in th« Bf^t&iet Work- 
bouiie. In these raseB the Bolc victimH ncro bays under the age of tvehe. 
The girU and tt(biltH encaped. In all epidemics children are largely afiected, 
for unlike UphuA, of \t'htrh eerebm-tipiiia] fever Wiyi nt one time mipposcd 
to he mcrvlT a. vwicty. the di»c-ii»c I't-iwlily uttocks youufi mihivcts, and ia 
most fatal in rmly lifi.'. j\Jtlioii|'bDotgonemt4Kl, like typhuH, by inHonilar^ 
onnditioiiH, tlie onsel; of the fever seemi) to be favouwd by them ; and foid 
air, bad food (especially ergotized grain, aecordinR to I)r. KichartlBon), 
cxpuKiirc lucoldaud ditiiip, luid pb%iiuoal fatigue, uo doubt tend to encounigo 
th« Hpread of tluB fatal maludy. ^ 

Morbid Anatomy. — Tb» veueels of the pia ui&ter, both of the bmin andi 
cord, are concceted, and Ijiiuph is exuded into the Bu)«raclitioid tissue. ' 
Bouietimcs it ih alwi Dcen in the ventricles. It usualfy ronniRts of opiujuft 
purulent matter of a grecuish-vellou color. The amount VRj-ies, Ii ma; 
occur only in pntcheB, or mny be more ^nenJ. The 1^-mph i« especially 
abundant at. or is t^iiiined to, the base of the bmin — UBUally tlie posterior - 
pnriioi), the mirfnee of the luedtilla oblongata, and the upper pnrt of th«< 
A|)iual cord. There iitoflon onngeation of tlie subntance of tltc brain, and^ 
tlici-G tao,y bo hltouh vffiixitiu or ac'tucil tixlnk^'oaiition of blood. The cliomici 
pk'XUB is much congcBtftd, and the (.■cniwd part of the cord may be cov- 
ered with a thick layer of briglit-red vei^sels. In the worat cases of tb« 
flinnwir the blood K very dark in coloinr and uuuamtUy liquid. 

The exudntiun Hppt'jire to be thrown out with i,'reiit rupidity, for it mnj 
be found in mst^ nhtTe duutb occurred within u few houra of the chUd 
hcm\i attacked. Ehert and olbere bare found miri<ococci iu the purulent 
ctfusion of the mcuin^jeit, and accordiag to some obeervera the diaeaae ia] 
oaseutially duo to uiicro-orgauisms. 




Of Uie other orjpuis : the spleen im f^cnoiiUly iiniUtcrecl. Although 
BometimeB it, an a-«ll as tlie cither riM-ern. tuay be cung^Ht«d. There nin_y 
be BgnR of pleiirifly. and Hreitt«re(I pittches of hepatisatian may be noon iii 
tbe loiiKii- H i» eiud Umt Uw Agaunateil and aolttarv (;laaJs of tho intcfltinc! 
brre lieeo found in some cases to. ho swoUeii. 

A'(/m|rf«m*.— The iliswuM? ypiierally bcfjiim smKlsuly diirui;; sleep, hav- 
ing been preoeiled by few or no premonit<->i'j' symjitome. In eurtAin vaa&t 
nally the mililer ones — the ciiild mnv atmplain, if oM enough to do bo^ 
'of urBoderiiig tiKiu8. ami may s«*ni poorly for ft dny or two Iwforo the out- 
break ; bat there U seldom noythinfi; to fix the nt'UiitioQ before the first 
^le»t symptonis, of the disease moke their appeamtico. In rare eaaeit 
there may be besiinche, mniiting, anA general lenclemeBS for mme days 
preriotu to the actual bef^nning of the iUnpsR. 

As a rule, the first noticeublu feature is a ripsiir or a fit of coovuleions ; 
and the youuf^er the child, the more likely is the attack to be^iu with a 
cnnruUiveneizure. Somctimi^R Revere headache and vomiting may usher 
in the diseaae. If thr^ patient, im ia often the case, aeema heavy and 
Hlupid after the fit, hv «till kIiows by Iiih rt-HtlcssQUSM, hin iiioiluh luid crieu, 
and In' 6'equently carrying the hand lu the hvad, Chat he is sulTeriug se- 
tere pain. Tlie pupils are oontraded ; the pulue is quick, seldom lowered 
ju frequency ; the temperature (which should always be taken in the rec- 
tum) is 11^11-2" ; and tbe breathing i>* Inirrie'il. An early B^inptom is re- 
tmi'tioQ of the h«A(l uiion the shoulders. It bae been KUf^LicHtoil tlinl: this 
poeitioD is at first partly voluntary, torolicvc the pain (which wo know, fi-om 
the caae of tlie atlnli, bo he of a very nevere character) shooting down the 
back ; but it aoou bemnieH invotutitary from spaHraodic cont^raction of the 
BnaGlea of the nuclm It may oocur within a few hount cvf the onset of 
tbe illntw, and in rarely litTliiycd buyond iweuty'foar hours. Tbo tetaniu 
spasm of the muHcles of the ucf k rmiy extend to tbe vrholo back. th« jaws, 
or even the linibii, aud may be varied l>y clottio convulsive niovemeiits. 
In a ahort lime tlie crie» and maiLife^tatious of pain ceaA« as the senses be- 
eono iluller tuid the stujKtr incrcnAe^. If coiinciouHLeee ie Lost early and 
doea not returu, the i^yuiptoin in a vciy nmw ona 

About the a&c'oiid or bogitiniri}.; of the thin) day a herpetic eruption 
appears upon the face, and puiiiuric epnta may come out upon the gody 
anil limbs. ThU eniptjon, which ia not invariably present, has given to 
tlio dimaas one of ita names — " (q>otted fever. " 

Whea tho diaoaso is nt its hei<;ht, the child hes ou his side in the cot 
with bis head retracted, his liiolm Hesed, and his spine often rit^idly 
curved. Re la completely unconscious, but still remains uneasy and rest* 
JcM. often movinff one or both lower limbs nionotonoUHly. The pupils 
Are uow (generally dilated, tiMually idu^^ali, and jH-rbups unc(|uiil. Tiie 
lielly is flattened ; the boweU are constipated : the pulse and respirations 
are quicjieneth At intervab sjttums are noticed : Uie head is drawn more 
haekward, and the curve of the spine is increased. When tlie stupor is 
complete the bladder is evacuated invoUintarily, or there is retention of 

Iq bilal cases the conui continttes, the br^Athine iB accompanied by 
mitJini; within the chest, and the child sinks and dies. IS tbo case is to 
end favourably, the stupor crown letwi pTnfoimd and the rMtlesmeaa dimiii- 
l^lie rigiditi' is late iti relaxing, and ufiually the mind beBonies 
«3sar while the bead in etiU retnutcd upon the i^houldcra. 

The special symptoms above referred to vary considerably in severity 
particular caaes : — 


rEpidemio oeiebr^-npuuJ tuuiiiiigitia.) 

OniBM^niiAL {OT«r is a specific intlammatJon of Uie membnuies corci^ 
in^ tlio brnio nud corJ. The iQaWl;r is no mere loc«l disorder, l>ul. a 
bliHxl (liMMwe, of uhieli tbo iiiflftinnutory ailiBction of the meDiiigeH in the 
(uwtomieal expreBsioa It iiwiaUy prpvdils lb opitloiuioii, luid outbreaks 
of Uie (liseoae have been uot«d iu Tonous countn&A <(ndc:l,v difTering iu 
olimatic aniX ot1)f>r conditinnH. 

Qtmatiot'.—Thf epidemiou of Pcrebro-Bpinfil fev*"!" generally oeoirdur- 
injT the wUit<r months ; but ifKiliit«i ojimjh aro oft**!! itotiood for ftonie time 
before the (lii*ciise bttomcs more Ktiici-aJly difl'ui«.-d. Thus. iK-forc the epi- 
demie wbicli pi-e\-mled iu IreUiid in IHGI. Hpundiocues bad boeti obaenvd' 
in tho country for tNinii? yeiira Tbe (baetue uppeiUB to 1m> mildly infoctioiu. 
It fiutteus upuii old tutd youti;;, rich aii«l pour, L>ut uitdcH iippi-ur to he more 
lutljlf; tu KufftT from it tliuji feiiiidrH. In IHiii some ceuscn occ-tirred in the 
Dublin aiid Bray AVortliuiu^M. fiud sbortly afl«i-wanJs in the ilelfsBt Work- 
houee. In these casea the sole nctims wei-e boys under the age of tfr&tve. 
The girls and ulidts eHrjiiM><l. In all epirlemics clilldreii nre lArgely aSetAed, 
for unlike t^-])huit, of wiiirb cerebro>4ipiiial fever u'lvi at one time Biipposed 
to be Toerelj a variety, tlie flisiMbic roo-Iily fttuicks yoiing eubjocte, and is 
nioHt fatal in early life. Allhou^'h not [fcncnilod, like trphus, by insanitary 
cotidilionn, the oiiitet of tliR fever t>eeaiH to be favnuzeii by them ; and fojil 
air, bad food (espociaUy ei-Rotizcd gnun, accowling to Dr. KichnnlBou), 
oxpooure to cold, and dnmp^ :uid ph.mcal fittague, uu doubt toud to cnoooraga' 
the Hpread of thia fatal ualndy. 

Mojtiii Anaiomy. — The veiwels of the pia mater, both of the brain nnd 
oord, are confreRtcd, and K-mpb is exuded into thie aubarachnoid tJMus, 
Somotimcti it in ahso Keen iu the vontricW h. It usually coutdsta of opaqoa ' 
purxdeut matter of a gxeviiixh-velloiv color. T\w aiuuimt viiriea. Il may 
occur only in patchea, or may De more ^'uend. The lymph ia eBpe<^ally 
nbuntlaut at, or is confined to, the boae of the brain — usoaJly tbe posterior 
portion, the surface of the medulla oblongata, and the upper lutrt of the 
spina] cord. Tlitre isoften congestion of tbe gubatanoe of tho brain, and 
toere may be s^rouaeffusioQor ivctual exti'ftvaHation of blooib The chor^^td 
plexua ia miir.h cnngeBted, and tlie ccrvit-ol jiart of the corxl may be otiv* 
enxl with n thick layei* of hright-ned veSRela Iu the vorst caws of the 
diftoaao tho bloo^I is vcn,' dai'k in (>oloiir and niiiit<n.illy licjuid. 

The exudation appears to be thrown out with i;r«it rnpidi^, for it may 
l)e found in catWH wlare death otcurrcd within ii few bourn of tbe cbiUl 
being attacked. Kbert and otlten^ have found micrrucood iu the purulent 
•ffisuon of the ucuiugvH, and iK-i»rdiiig to some obseirer* tho diMiue ia 
tiaUy due to inicro-orgauisiOB. 


Of the other oTgaan : Ui« eploen U gosemUy 'Uiiftit«r«d, oltliough. 
•oiaeAimeH it an vmW aa the otlter visofm. may lio congested. There may 
b* ngn» of pleurisy, and sd'atterwi [latcfapB of liepntirjition may iie t*e«n in 
tlw lunfTfi- It ist saUl tiint tho a;^inat«d nad solitary gltuidst of tb« intesUoo 
lutTB been found in some cnsL-a to bo HWoUen. 

.Sym/rfuwix.— The diseuM* geiiei-ally be},'iii8 suddenly during Hleep. hav* 
ing been preoe<le<l hy few or no promoiiitury Bymptoma In certain eases 
— usuidly the uitlder onea — tUe oiiild may cotuplaiu, if old eiiottgh to do tto, 
of wandfriufj fuiiiiK. nii<l may swroi poorly for a day ot (wo before the out- 
break ; but there its ueldum iiuythiii<^ to lt\ tlio nitciiliou before the first 
violent et-mptoioB of the disease make tlieir Bi)]>oflrance. In rare cases 
iliere iimy he beaidaclie, vomiting, and general tenderoem for some dill's 
prenouM to the actual beginning of tlie Ulu«8a. 

As A rale, the fintt notii!«able future is a rit^nur or a fit of cotinilnonB; 
and the younger the chUd. tho more likely is tho attack to bcRin 'vritb a 
oonTuUive Heizurf. SometimPB severe headache and vomiting may usher 
in the din^nsa If the mtient, as is often the case, seems besvy and 
■topid after tlta fit, he stilL shotn by his rcetlesBness, bis moans and «riw, 
and by fri'^iut^tttly eoiTyitig the hand to the hoH*!, that bo is Hufforiug bo- 
vere pain. The pupilH !ire contracted ; the uulao is quick, wldom lowered 
in fre<juencr ; the temperatun? (whirh ahoiud always be taken in the reo- 
tuiu) is 101 -2 : tiiid Uie bri.-:at)iiii^ 18 hurnc<l. An early eyniptom is re- 
tmction of tliv h«tul uix»n the Hlioulilem It baa been auggeeted that this 
pomtion is at rirxtpiirLly voluntary, to relieve the pain (which we know, from 
the case of the adult, to be of a very severe character) shooting down the 
bark ; but it aoon bet'omeH invoUiiitary from spaRmodic imntraction of the 
miifuOes of the nueha It may oi»mr nithin a few hours of Uie onitet of 
the illness, and is nuvly delayed beyond tweoty-four hour*. The tetasio 
spasm of the muscles of Ihc tuxk may extend to the vrliolu Iwck, the jaws, 
or even the limbs, atid may be ^niried by clonic convuhtive movementa 
In a Hboit time the (tries and manifeHtatious of pain cease as the asnses be- 
come iluller and the stupor iiicrcnees. If consciouenesa is lost eu^ *I>^ 
does uot reluru, thu s^'uiptoiu is a vert' ^rntre one. 

About the second or be^inniu}^ of th«i third day a herpetic eruption 
appears upon the face, and piirpuric apota mAj eome out upon the body 
utd limbs. This eruption, whirli itt not invariably present, has given to 
the diseaM one of its names — " sitotleil fever. " 

When the disease in nt its hoight, the ohlld Ite^ ou his side in tli'e oot 
•Kith his head retracted, hin hmltH Sexe<i and hia spine often rigidly 
corred. He ia completely nnconttrious, hut still remniriH uneasy and rest- 
leas, often moving one or both lower limba monotonously. The pupils 
art) now gonorally dilated, umiiilly sluggish, and perha]!!* unequaL The 
beOy is Usttened : the bowels arc comttipated ; thu pulse and respirations 
are quickened. At inlervidii spisniH are noticed ; the head is dranii more 
btekvard, and the curve of the epine is increa!<ed. When the atupor is 
complete the bladder ia ex-nouated ia^'oluntahly, or there is relentiou of 

In fatal cftsee tlie coma eontinuee, the brentliiug is accompanied hy 
raltliug nithin the chest, and the child sinks and diea If the caee is to 
end favounildy, the Htujtiir grovrs less profound and the rfstleasneasdimin- 
Ujsa. The riffidi^ is late in relaxing, and URually the mind becomes 
daar vhOa tbo Oand is «til] retrnoted upon tJie Hboulih-ni. 

Tlio special sym)itomJt above referred to vary coiuddcmbly in aeverity 
in particular case^ ; — 




cHArTER vni. 

(Epidontc c4mbro-ii|iinikI mnoingitia.) 

CmijoQHHm'AL few ix n 8]xiei1ip inftommfttion of ttin momlintnofl comr- 
injt ibia bmiD and ourd. Tbv m&lud.Y is no mero local dufurdex, but a 
blood diseane, of which the inflatiinmtory affectiou of Uit> uioDuigtrs is the 
oiiatoinicfU cxjM^teiioQ. It uioiimv prevaihi iii epidtftuii-s. aud nutbreaks 
of the diBcaso hftvo been noted iu TiuiuuH countries widely diiferinff in-i 
olimativ uud other oouditiuuH. 

GtuMtioiK—TitB vyuUmk'H of cerebro-spinnl f«v«r gouenUy occur dur- 
ing tha winter moulliii ; bvit itMlAtcd viur^n sirv oft^.^ uoticed for aonie time 
befofe thfl diseaee becomes more generally diSuaed. Thua before tJie epi- 
demic which pre^'oiled in Ireland in IKOT. ii]xiiadi(; caHes hsd been obwrred . 
in the conntri- for itonie yenrs. The diwntto Appeam to bo mildly iaftwtioua. 
It frmtMiij n)H>iL old and jount;, rich ftnd poor, bat maleB appeAT to bo more 
Hiihle to HiinL-r from it tliau fcmuJi.'H. In 18-lC Mome owee ocoiiiTed in the 
Diiblbi and IJmy Workliouse»i. imd nbortly sfterwanlH in the ItplfRRt Work- 
hoiiiw. In thpaft eOHPR the sole victims wei-o boys iin<ler the- age of Iwolvc. 
The twirls and lulultti enciiped. Li all cpidvutica childrt^n axv lm>;L-ly ofTRctetl, 
for unlike t^-phiis. of which (.■orcbro-»piual fever wigi at one timu supposed 
to lie merely a variety, the diHease reiulily iitiacka youUR eubjeota, and ia 
most fatal iu eai'l,>' bfe. Although not generated, like trphoii, by iaisuiitiiry 
ouudilioiiH. the onset of the fever seems to be favonn-ii by them ; and fold 
iiir, bad fooil (cspt'eijilly ergotiv.e<l gnin, aceordinfj to Dr. KlcbanUnti), 
exposure to cold and <lAiup, nnd phynenl &tif^e, no doubt tend to encoarag» ' 
the flpreiui of this fatal malady. 

Mvtiiid AiiiUomi/. — Tlie veH!«ela of tlie pia mnter. both of the Iwiiiu and 
oord, an ooogastod, nnd t^iiiijih is exudrd into the mihamchrioid tiueue. 
SometimeH it u oIbo kccu iii the veutriclcK. It ujiually (.-omsieis of opsque 
piindeut mutter of a grftuiab-vcllow color. TLk luuount Taries. It raaj 
(X!cur only in patelieR, or may W more geuend. The lymph i» c<ij>eoitUly 
abundant at, or is cmnlined to, the base of the brain — usually the p08t«hor ' 
piirtiou, thu tfurfnee of the iiiedidk oblongata, aiid the upper pivrt of the 
tpiiul eord. Thtre u(oft«u cou^^lion of the (tiibxtaoce of the brain, and 
there may he Herouaet^uHiooor actnideKtraviuvLtion of blood. The choroid 
plexus is much congested, aud the cervical part of the cord may be txiv- 
ered with a thick layer of bright-i-eil vessels. In the worst caws of the 
disoaae tho blood ik very dark in coloui- luid uiiiiHuidly liquid. 

The exudation appears to bo thrown out with <„i>?nt mpidity, for it may 
be found in ranea where death occurred within a few houre of tlie child 
being attacked. F.bert and olherK liave found mictocood in the pumlent^ 
efihition of tho nicningeM, and aeeording to some obswreni the dlMaae ia] 
oaHcutiidly duo to micro-orgauiiiuu). 




Of the other organs : Ui« ^leen is genei^y unaltered, nltbougli 

WiaMtimfs it, a» well as the other vim^m, ma; be congesle*! TLer» rmiy 

Ite ligns of piRuriNy. ftnd scattorad pntclic* of hepatization may ba Kuen iu 

tLe lun<pi. It 18 said tliat tho ajifininntod Ami nolitorr ghux^s of Uio intfstuie 

tmve I>ccti fnunil in Homo gohob to ha swollt-a. 

S>tmjrliiiwi. — The (IiBeaiie generaUj- b^tpuH middonly daring deep, Uat- 
tng ^Mv.t^ prG(^eik-il liy few or no preinoniU>n,' Hjinptnms. In certain nises 
— UBiully tlic milder oiit;;» — tbv uliild nuiy c:<itupluiii, if old [iti(>U(;li to do no, 
of wandcriuts IkuR", imd muy hl^l-iu jMurly for n dny or two Iiefore the out- 
break ; but thorp is H(>ldoin nnytlung to lix the ntteiition before the first 
violent svTuptoius. of the disease make their nppearanc-e. Iii r*r« csmh 
lliere msy bo hcntluche, voiuitiug. nad general tendemeiui for wnut- days 
prerioQs to the actual be^^iniiing of tbv illuee§. 

As a rale, the first noticeable feature is a rigoiir or a fit of convqitgions ; 
aod the younger the child, the mare likely is the attack to I)e*]^in irith a 
coDTulsii'e tlMZllr(^. Sometimes severe lieacWhe and Toiniting may iiither 
in the disease. If tho pntieni, as i» often the ease, seQiaa honv^- luid 
Stupid after the tit, he still shows by his restlAMDeea, his moiuis and'criee. 
and by frequently carrying tlie band t<i the head, that he in suflTerinR se- 
vere pain. Tiie pnpils are contraoted ; the piilst^ in c|ui<?k, Moldnui Inwerpd 
in frequ(>ney ; tlic tempemtiire (»'hi<-h Rbonld alwayn \yy t&ken in the roe- 
tUTu) is 101-2" ; und tbe breathini; is Imirned. Ati curly s^inptom is re- 
tnrlion of the liesd iiim)I1 thv Hbciul iters. It Ims been Kit^i^exted timl this 
position is ut first psu-tfy voluntajn-, to relieve the pain (wliich we know, from 
the ca»e of the a^lult, to be of a ver>' itevere character) eliootiug down the 
back ; but it soon beconit^K invobiutfir^' fi-om Hptwmodit: contraction of the 
mttsclea of the uucIia It tniiy ocl-ui- within u ft^u-houraof the onset of 
the illness, and is rarely delayed beyond twenty-four hours. The tetanic 
spasm of the muwrles of the neck may PTitend to tlie whole hack, the jawa; 
or even the linibx, and may be raried by rlooic convulsive niovemeDlsi 
In a short time the cn<** and nianifestntinns of pain eeooe as the SODMS Iw- 
oome dallvr and tbv stupor iucrenses. If cutmciousness is lost early and 
does mit return, the (rnuptum is a rery prave (me. 

About the second or tiepiuuinf' of the tliird dny a herpetic eruption 
appean upon the face, and purpuric spobi may come out upon the body 
and limlM 'lliiM cmptiou, which is not invariably proscnt, lias f^rou to 
lilt- di>M-ase one u( its uiunes — " spotted fever. " 

When the disease is at its tiei^bt, the child lies on his side in the cot 
witl) his bead ratraeted, liis IiuiIm Heted, aud his aytine often rigidly 
carvpd. He is completely uuconscious, but still remaius uneasy and i-eat- 
Jess, oftt-Q moving one or both lower limbs monotonously. The pupils 
kre uow f^onerally dilated, usually slnt^gish, end perhaps unequal The 
belly is flattened ; the bowels are constipated ; the pulse and renpiratioas 
are ([uickened. At internals spaamH are noticed ; tJie bend is dranii more 
baekwanl, and tlio curve of ttic spine i» inf>roa«4>d. When tlie stupor is 
complete the bladder is v^'ocuatt'd iiivulimtju'ily, or tboru in rcioation of 

In htal eaaea tlie coma continues, the breathing is accompanied by 
nttliuj; nitliin the chei^t, aud the child sinks and diet^ If the case is to 
end favourably, the stupor t;rowH lerta profound and the restlessness dimin- 
isbe& Tlie ri^tidity is late in nlaxing, and usuidiv the miud booomes 
ideur whil« the head is still retracted upon the sboubUrs. 

The iqiedal symptoms above referred to vary consiclembly in se^-erity 
in partioular cases : — 


The fever is verj' vniiable aod hns na rv^Ur couree. Tb* intemil 
beat, BB tented b; u thei-tuomeler inmxluccd into tlu^ nxttiini, i<i f^RRmllj 
lugber than the surface of iLo bodv ; but uvcii iii the r«ctum the mert-itty 
maj tnHy mftrk a degree over thu noriniil toiupLTNtun.-. M ntlif>r timra it 
rises to 104" or 105°, If eaii}' collapso cuiqh on, the teiui>erature miiy 
sink to below tbe nornial level. 

The ttltin eniption i» a valiuiblo sign. In »oiiie epideuiicM it is u rare 
symptoui ; iii ouien almost all tlie cases exhibit a luiiubfr of |)im)una 
ipots. In every recorded serious nntbrvak both thv mu-ulattj and tba 
noiHnaculated fomu of tbe dittcaw.' luve been obserred, altbougb one mar 
have be«Q more common tliiui tbe other. Tlie nwh coDsists of dn.i-k 
purple spotn or bloti'lipR diie to cITuKion of diiuvtlvecl biriiintin ioto thf> Irua 
skin andarcoU titwuc iK-nonth it. They grnenUly ncoupy thf- Ifififs, Itanda, 
Eaoc, brick, and neck. Thuy arv wimdtinita Hli{,'litly clcMited, and vart- in 
size from a ptn*H h»ad to a waUiut. Awwrdiiig u> Dr. J, A. SlarKton'n ol>- 
serralioiia in the epidemic wbicb occurred in Ireland iu the year 184i7, 
Utcrc is uo uei:ei«<ary relation between tlie <x!curreuce, Ibe number, and tlio 
extent of thu sputit ii^>uu tbe skin aitd the nicount of the intm-cnuiial and 
iDtra-epiuiiI miucbiof. Dr. Miiputbi>r, r«ferriuD to Ibe Bame epi^Iemic, 
stAtes that the spots cannot be produced artibciallT by preesure on the 
Hkin an in tnie purpura. BeftideH the peteohi«, tliere may be bt^rpes. 
urLicaria, and patcheii of errthenia or roseola. Tlie skin may bav* a 
dnskj lint and is often moist. Cen-hral Hiifili in not a marked nymptoin. 

Tbe mental cQndition also varies in diSentit cases. When tbe diM-ase 
ifi violent and death orcurs early, the child may be uncxinftcinua from the 
tii-st- In other (aises stupor iximeR on by the second or tliird day. In Uio 
uiilik-st cases the uiind may be little aOt-vted, or there nn\\ hv iHiglit de- 
lirium with cuiioiia liiilluciiuitiuus. niuH, Dr. Lt-wiM HmitU rcfen* to a 
ease iu which the chUd answered questiouM with perfect nleoniess, but 
eonstautly mitttook his mother for another person. Ustudly, in all cases 
before death Uie eonta is profound. 

The pains referred to tbe bead ond ^ine are always n distresnug and 
promineut symptoni. They are often so Mvere tuat the child, until 
lie becomes comatose, is constantly monninf* and screaming. The paiu is 
increaaeil by niovementa of the back, and especiidly by attempts to press 
the head forward. The general lenderueiw of the skin odtis greatly to the 
child's tliftoonifort ; and sometimes a touHi on the body, »8 in moriiif* him 
to alter bis jiosilioii. i-ausos the p-eutcst diKtress. 

In some eiwes pandyhis i« noticed. It is. bowei-w, a comparatiTBly rare 
nyniptnm, nn<l in ummlly ]>iu-tiid, being limited to one or more hmb«. It 
may alTuct thi: cvrcbnd uervets cspmally the third, the si.iLth, luid the 
facial The U-!fiou of the iierve-truuks is due to ])urul«nt iiiilltrution of 
the iieurilemiun. or to (.-uuti-Mctton of the 1iy|^KTpla«tic connective tifuue of 
the nerve-sheath. In cases of recovery the pandysie may last through life, 
but souietinieH it priRsea ofT as tJie patient improves. 

CouviiUious. general or partial, are comparatively common iu tlie case 
of children, cei-tainly much more common in them than in tlM adult Tbay 
are esjiecially frequent iu tbe more sovorv foizmt of the difwnnn TJkeclonio 
spasms HonietimeM alternate with touir contractions ; and may be general 
or limited lo one-linlf of the body. Nystagmus may be noticed. 

Vomitiiit; is scklom absent at tbe begiimiiig of an attack. It is oftca 
severe, and like all fonuu of nervous vomiliDg is independent of taking 
food. Tliethirst is greeit. Couttipstion is the rule ; althoughia some epi- 
demics tbe diaeaae h^ been noticed to be ushered in by purging as well oa 



▼omiting, Th<i tont](iio may bo clciin or furred ; towimls tlie end of the 
di»easc it bocumcs dry. Abdominal pain, if prsHenf, is like the hypencH- 
tbesia of nervDUK oripD. Tho belly m wldom retnirted, and nerer to Uto 
d«gnw observed in cases of tuljerculiir meiuDgitis. OwiUQOQfiUy it in full 
or «<mt tytapauitio. Thn iiplc«n is somotiiDM «iiliu-|:(0ct. 

T!i» papils fir« iit first contriii:t<;>L but dilato as the stupor deepona 

Tbey are often sliiRgisU. and may be unequid in size. A Hquinl is nom^ 

!■ times noticed, lilindnes may ooour from kcmtitia owing to imperfiMt 

^PdoHure of Uie vyelidu, or from ucuro-rt-tiiiitia due to tLt; 8pr«ad of Iho 

^K pnmleut iuflauiiuatioii along the optit; uHrv(< ; »iid in tf>um ruit^ ciuwA tlie 

^r eT«ball ban be«n known to bo coiiipk-t«]y debtroycd by HuppuruLioii. Tb« 

hearing may be ateo Hfre«t«d. A temporary deafness witU noises in the 

bead may occur dtii-ing tJie first days of tliedioease and be aitern-anlB re- 

rcrv(>r<^1 from. If it occur latJ^r, it w probnbly duo in moftt oasea to purulout 

■ inflamroatton i^itbiii the Iftb^-rintli. Tliift form of d^afttom is nmially bi- 
lateraL complete, and permanent ; and Lf Uio patient be a yoang child, may 
leail to ilfaf-iiiiitinm. 

The pulM> in Keldom otherwiito than fjuickened ; but it rarely attains at 

fint A high degree of Erequeocyt and is subject to rapid alterunUous. It in 

not often intemittoni bat ia uaually vciy feeble. Thf brcatliinff is also 

I i]utok(!ued, and iii often irr»[;iilAr and interrupted witli td^lm. The nonnal 

Nation between the pultw and the renpiratiou is presented. 

~^Tlte lu-ine inoften oatund in ipiaDtity, «olor, aud renctioD. Ithnsbeen 

to contain albumen aud ev«n blood 

Tlif re are laauj differ«nooti in tho t'nrious caees of c6robro-»]>iDal fever 

met with in the course of tho tnme epidemic In some the eymptoms from 

the liret are indicative of profound hluod-poisoninp. OonsdoufineBM is nf- 

Pfectei) fmm the lieginuing ; tJiere in extromc proxtmlion, a feeble tlutter- 
iDf; pul»e, and labonnl l>TOQtJiinR. Tlu»n 8pot« appear early and are ot- 
tensivL-ly diiitributcd. Tho Ktupor doL-pens into coma, luid di'iitli takes 
pliuv with HtartUug rapidity. In theHe ca«es the more Bjiecial symptums 
Rriaing from the looal iiifUtmrnritioii are overaliadowed by those dependent 
upon the gvuerol eomlitiou, ujid the ]}atieut dit^ from blood -poiwutU);. lu 
another cbai uf cases the symptoma of cLnYtbro-sptual inftiimmatiou pre- 
dominate, and tho TOon nrarkod phaaomena are the <.-oiivuItiLouB, the draw- 
^■fog liaekward of the head, the hypertesthesia, and the tetanic conlTaetion of 
^BnuM'le^ In this form if ttie diseaw end unfavourably, ih^ath is owing mainly 
^■toibe local lewon. Aannde, Oie affection is moat severe whfii the ej^iidemio 
^Fia «till young. As t)ie eaucH ^t more numerous they bcconio milder ; and 
■t tlut end oi the epidemic it ia common for recoveries to take place. 

In WHne inatoncea curioua intenuis^ionH oircur in the diHeiLse. Tbeiie 
may be found quite at tho onset, evident premonitory syiii])tnmaappDnring, 
DBMittg oB. and returning, pcrhapM several times, befure tlie actual uut- 
Draak oecurv. In otlK^-r eaaea during bbe coumo uf thi; diHCiifie mon^' orlcsa 
coiDplete remisisian of Uie imnptomB histing for several houn. or a day may 
tike plare. Aooording to I>r. Vrey, this ia ^-ery common at the end of the 
second or third day. A^^in, during oonvolesceucc the stitno variatioDS 
may b« seen, the headache aud letrat-tiou of head being at times dixlress- 
ing, at other times ecareely nolieenble. 

According to Dr. Oaw Hedin, of Stockholm, infanta under twelve 
months old are especially liable to tJie dinease. At this early age the ill> 
DSH generally enda fatally ; but sometinieH mild casfs are observed lasting 
lima • day to a wook- This physioian, who at thi"- Orphan Asylum of 
Sjoekliohn bod loauy opjKirtuuitteti uf ubaening tUo uiuludy, itiatea that tho 


Tbe ferer u very VHrUble nnci ha» no ro^ruhu- couiw. Tbe intenial 
beat, aa tested by a therrnometor intjoducwl into the rectum, ia generaliy 
higher than the sui-face of the bcxly ; but even in the rectun) tbe nierruir 
duty only mark a degree over the normal tempentturf. At other tiitiHg it 
riM-8 to 104' or 105'. If eaxiy coVupae conic on, tli« U^miMTAtiiro m&j 
ftiuk to below the uormnl level. 

TUl- akin uniption in a vuluiiblo nijiu. In noiue cptdeinica it ia a rare 
gymptom ; in others aliiiont all the oaiwB «slubit a number of jmrpurie 
wpaU. In everv recon-|«d aeriotis outbreak both the nuculAt«(l niu) tha 
DOa-iDOcukted ionim of the iliaeoaft bare been obeerred. altJiougli ouu may 
have been mure cumiuon than the other. The rash consiMtii of dark 
puiplti siKitH i^r blotfOieM due to cffiiHOU of disHolved bji'itiatiii into tlio Imi 
skin and areola tiaeue beneath it. Thcr generally occupy the legs, haud% 
face, back, and neck. They lu-e tmiuetimea alightly elerated, and vary ia 
«izo from a pin's head to n wiUiiuL Arasirding to IJr. J. A. Slnretoii'n olv 
MPr&tioiis in the «pi<letnic whioli o<>4>iirr«<l in Ireland iu tbo year 18ti7, 
there is no neceHmrr relation between the occurrence, the number, and Uie 
extent of the npotH upon tbe akin and the amount of the intraH^ranial and 
iiitr«'«ipinnl minphicf. Dr. 31npot}ier, referring to the mmo opiilemic, 
states that the Kpota cannol hu produoei.1 artitirially by pi-oaauro on tiie 
iddn OH in true purijura. Beaidra* Ibo pt^tecliiiu. there may b« berpea. 
urticaria, and patt-hwi of erytbeina or roMeola The skin may have a 
duskr tint and is often moist. C«rebral flush is not a marked ayraptooi. 

I'iie mental condition »]») rnrioa in difierent caaeA. AVheu ue diaettfS 
is violent and de«th occurs early, tlto rliild may )h> uuconacioiia from tlia 
fii-Bt Iu other eoiMm 8tu|)or roiciCH on l>y tlio fi«^><:ond or third day. Iu the 
mildest cases tlie mind may be little afltx-tcd, or there lunv he slight de- 
lirium with curious Imlluriimlioiis. nius. Dr. Lewis Smith refera to a 
cam in wliieh tJie (^llill1 answered quostioiiK with perfect cleanieii% bnt 
constantly mistook tiis mother for auotbor person. UmiiUly, in all cams 
bafore deatti the coma is profound. 

The paina referred to the head and apine are bIwhts a diHtreaaing and 

Erominont symptotn. They are often so severe tijat the child, until 
u becomM cotuato»e, ia coiisUuiUy moaning and sereamiug. the pain ia 
increased by moveinentH of the bock, and especially by aLl«uipts to prvm 
the bead forward. Tke geut>nil U>udenie»« of tlie skin udils^jreatly to tbe 
chitd'a discomfoi-t ; and sometimes it touch ou the body, ub in monng him 
to alter hit* postilion, clauses the greatest distj-esa. 

In iKome eaws jmnil ii-Kiw !« nntjead. It is. however, a comparatively rare 
symptom, and in iwmilly pfti-tinl. being limited to on© or moro liniba. It 
may allVtct the cerebral nerves, fH]K.'cially the third, the sixtli, and the 
facial. The leBion of the ner^-e-ti-unkn ia due to purulent uifiltration of 
the neurilerama, or to pontnu'tinu of the hyp^'rplaslie connective tissue of 
tbe nerve-sheath. Iu cruicit of recovery the paralvBia may luat tluough life, 
but sometimes it passes off ua the patieuL improves. 

ConTulRionB, general or partial, are coinijaratively common in tbe case 
of 'childrou. ccrhuuly much more common in t]iem than in the adult They 
are espeeiidly fn>qucnt iu the more aevere forms of lite diaease. The clonic 
apasms sometuues altomat« wltb tonic contmctioua ; and may be general 
or limited to one-half of tbe body. Nystagmue may be notioeo. 

Votaitiug is seldom absent st th« iM^Luning of an attack. It is often 
Mrere. and like aH forms of nervous vomiting Is independent of taking 
food. Tlietltirat ia gront. Constipation is the rule ; although in aome api* 
demica the dhieoae has been ooticc>.l to he uahcrcd in by purging ax well m 



[voiailins- The ton^e lon^ be clean or furrod ; townrdti tlio ond of Uie 
^diMMM it becomes diy. Abdoiuiual p&m. U preseat, is like Uio bTpcrns- 
, of norvouH urigiu. Tliu belly is svldom retracteil, and novcr to the 
degree obnerv«<l iu ewwa ot tul^ercular meuiugitiii. OdtasioDaUy it jh full 
or rwB tjiDpaaitic. Th^ spleen is sometimes enUif^. 

Tlir; pupila HriL' lit Hi-^t coDtncted, but (Uluto us tlie sttipor dcopooK. 
Tbey are ofl«n alu"^sh, ami may be imwj^iul in »ue. A Bquint i» some- 
times noticed. Bliiidnesa may occur from kppatitis owing to intperfact 
closiuc of the «yeli(U, or fi'om neui-o-i-etiuiti» due to tlie spread of tlte 
)t iutlftniiimtiou ali^ng the optio nerve ; rtiid Iu some nire cuaes the 
hnu bi'Oii known to be coraplotoly dcBtn\yedl>y mippurMtiou. Th« 
: li«ariiig nuty l>o Also tiffoeted. A tompor&ry deafness ^tb ttokes in iba 
lieul mar otxnir during the firHt dnyti of the ditteaee and be aftervranla re- 
eorervd trotn. If it ocrur later, it \h prolxtbly line in roost caaos to purulent 
inAuiimation witltin the labyrinth. Thii« form of dcnfnom is ukiulHv bi- 
\ latunil, c'omplcft!, lui J purmiuioiit ; and if tlic patient bo a young nliild, msy 
lead to d(.-af-muti»m. 

The puhie IK seldom otherwise than tjuifkened ; but it rarely attains at 
I first n bif^h degree of frequency, and in subject to rBpi<l alteruntioan. It is 
[aot oltvn iuteniiitteut. but i.^ ii^iiftlly very ftt-blc. Tbt; brcjithiiiK is also 
I qiiii-kuued, and in of(i-n irrvgiilar and interrupted with iugh& The uonual 
iTPlntion between the ptil»c and thu respiration is preaen-ed. 

The urine is often natural in quant tty. color, luid reat'tion. It baHbeea 
Imcnm to contain albumen and even blood. 

Thore are innny rfifferenoeB in t]i© viiriotis ca«e» of eoreViro-siMnal foroi* 
iXMt with in the oottrse of tho «ame «pid»niic In some the syniptome from 
the first arp imbcative of profound blood-poisoning'. CousciouioiesM w af- 
fected from the beginning; there is extreme praitration. a feeble flutter- 
ing pulse, and labored breathing, llien spots appear early and are ox- 
teuurely tlifitributeJ. Tbu tttupor ilucpons iuto comn, and dcjtlh takes 
plaoe with startling rapiility. In tliese casex the more sjierial nyuiptoms 
aiisiag from the local inthLmiuiition lire overshadowed by those dependent 
upon the gtitieral condition, and the patient dies from blood-poisomug. Iu 
another ckiss of canes the Hynipt(>ni» of cei-ubro-spiuid iiiHammatioD pre- 
domiDate. and the mori- marked phoiiomttua are the convulsionB, the draw- 
' ig iMckvrard of th« head, tbo h%'pora^theBia, and the tetanic contraction of 
luscles. In this form if the diseikse end nnfaTourably. death isomctg mainly 
|to the local lesion. As a nile, the tLflisotioD is most severe when tlie epidemic 
fin still young. As tlio camm get more numerous th«3' bct^nine luilder ; and 
at tbo out] of tho epidemic it ik commoii for recoveries to take place. 

bi some instuucL-s uuriouN iutermissions ocicur in tlie lUiKHae. TIichc 
may be fouml quite at the onset, endeut premonitory B^^^ptomB appearing, 
ofl; ana returning, perliaps several times, before the actual out- 
occurs. In otlwr cases during Uie couive of tlie diBoaea more or less 
impk*t« remission of tlie M'liiptoms Itistiug for several boun. or a day may 
' take plaiv. Aecordiug to Dr. Frey, this is vert' common iit the eD<l of the 
Mcontl or third <lay. Again, during eonvalesoence the same Tarintioua 
amy be neen, tlie beiidache and retmt^tion of bead lieing at times diatrt-ns- 
isg, »t other times scarcely uotii^onlilo. 

According to Dr. Oscar Medio, of Stockholm, inftmta ander twelve 
monthB okl are es]>ecially liable to tiic disciiee. vVt this early age the ill- 
'MM general^ ends fatally ; but HometimeH milil cases are observed lasting 
Inm ftdAyto a week. Tliis physimn, who at the Orjihiiu .Vaylum of 
jh^iitinim JuiJ ntiuiy oppui-tuutlieu of olMMirviug the uialauy, statin that the 


inilil cams togaiL nith U^ver, BnninolMic^ and twitchiuffs (lurinf; «](«p. ^i 
moA iustaBMs there vere othfr Byza|>toiiu; ficpecuUly daring aldep, Hurh na 
restlessness, great Iteftt of hwwl, cbau;;(.tt iu tUo colour of the face and in the 
aeiwilnli^ of tlie body. In a few ot the mitiler canes slight cnnMilsive 
«p«um8 urore notioed, with rigiditj of the limbs nndueck, stnbismiis, luiil di> 
latatiou of tbopupiU i but in ttudi aum Ui«iie evmploms Hoon disxppeaivd. 
Iu nil the epidemios wbioli came uu(I«<r Dr. MeJin'K obtu-rvalion such mild 
coaee were the cxoeption, and a large prt^rtiou of the infauts died. In 
the «ev«rvr forma tlK> bvmploiiw lUd not differ fi-oiu Ihoee obaerTod in oldtr 

Dr. Jlediu, like other ohften'er* who have had opportunities of etudj- 
ing this form of illness, spoaks of a pneomonia of n lew type, occurring 
without ueiTous (t^vniptouiH, an bnin^ frequently pi-eseut in t-piik-niics of 
oerehi-o-Kpinal fever ; and hnldn n-itJi them tliat iu 8u<-h casn's. tlie iufeeli^'e 
inftterial nttJM?k8 the Umffn in phu>e of the cervbnU membranes. Still, 
monin^^tiit ni»y bo present iu uuch ciuk-s, lUthoujjh it,pvB« riH« to no H>-nii>- 
towB ; for in souie iostaiices whej-e diiniijjr lifn the Hvmploinii were exclu- 
miely pit III lo nary, inHniunintioa of Ihe cerebral and Rpiiiid nteninf^nn wiu 
discovL-red on pont-iuuitfui exajuinnttun of Uiu IhhIv. iic«idcH pneumonia, 
peri- Htid eudo-furditiK, plvurinj, parotitia, and purulont effusion into the 
joiutH may be (»>mpliciLtiou8 of the disenae. 

The durstioQ of the attaclca is very variable. Death may take plaee in 
Bre or aix tioura in the iiio8t luoliguanfc forms of the dist^unijer. In other 
coses the lUnesH ma>' be prolouijed for one. two, tlutM*. or four weeks, or 
cvon longer. Convuletieeuce iu always slow, and is oft«!u iuteriuitteut. A 
profoimd debility, lasting for a long time aft«r the fever is at an end, is one 
of the characti^rittticfl of tlie malady. 

IJiaffiinaiti. — ICvori' ettae of rifi.'id retra^'tion of tlie head in a child is not 
one of «'cr<l>r(i-8piniU fever, The 6\T«ptoni is the ronttecpienee of a bano 
moniu^^Us Hprcading to tlie cenHcal portion of Ui« R|)iiiii] coal ; and it may 
therefore be pi-esent in any cam wh«re tlie membranes of the brain are tlie 
seat of itillamination. It is uot uncommon iu the course of a tuberL-ular 

Cereliro-spiual fever not only giveti rise to severe local symptoius, but 
is flleu aecorouamed by mure general pheuomeua iudicutiug a prufeuud co»- 
stitntioual affection. Its epioemie fonn, its violent and abrupt onset the 
extreme debility wliich is invariahlv present, and the petechial mah, remove 
the diMAMf fi-om the list of purely ^ocal diHonlei-s, and amply juMti^ ita l>e- 
ing rankci] ainougst the speetl^c fevers. Tlio diaoase wviant onetime hnld to 
be merely a form of tj^ihus fever complicated with meningitis ; but tha 
difference between the two ditwases areneitlier iiudgnificAnt nor few. Cera- 
'bro-spinal fever prevails etpially amoQgHt tlie rieh and tlie poor ; it porticu- 
llirly riffeots children, and is very fotol to them ; it runa a rapid oourso, 
ofttiu cauniii-; dc-uth in a few hours ; ita tt-mpcniture im a rul« is liltic ele- 
vated ; the rapidity of the pulse is mtiderate. imd when the fever i» high, 
is not inoreased hi proportion to the degree of pyrexia (indee^l, occorduig 
to some observers, it dues uot become ntpid imtil the tcmpuruture falU) ; 
lastly, retraction of the head is one of the most couunon Bymptuma, 

Tyiihiis loves "fever haunta/'aud seldom attacks the well-to-do; it 
rarely affects cLildreo, and Lf it tie, riuis in tbew as a rule an eq»><unlly 
favourable course ; its durntiou is longer, and eveu bi tite adult it rarely up- 
lienra in the ovi-rwliehmug aud uialiguaiit form no often twen in caaes of 
corebro-spinal fever ; liutly, meuingitu with retracUou of tLe bead in a rai-e 



TIio (lia^^iosifi of r^rebroHpina] fever is miicli cftsiiT iu tbe mulnt of an 

Sidmiiiv of tiw (liHOiuo. Tlio itbnujt (uiil viuleut oub«1, tJie uevere pain in 
i: head and tipiiiri, the romitin^, tho r«tmctionofth«lieft<l, tbefieuvi-iil stu- 
por, and tlt» jiotechiat nod other vruptinQs — Uiia ennibiiiat.inn of prufouud 
cuiutntiitjoiud svmpbHii!) with nervona excitenifint follon-od by dtvpremioti, 
u saffictentljr obanicteristie. eHpm^inJIv if nt the nnmo time, iis often hap- 
peD8, the t«mperatur« is oaly inodonit«l,v raised uud ™rie« iirepiilurlv. Li 
eiBee of amplv rcruhro-Bpiuul mcuiujjitis the rL*tn»rtioii of the lieml in not 
aoextreui^, nnd the KlifiiteaH uud pidii lu the iijtiiiR, th<! Ii/pcn«j$th«ein, aud 
th« pains in th« joiuta ai-e seldom present. As n rule, too, tlic uon-eppciBc 
diaeaae is preceded bv protlroumta aud runH a 1e.ts rutiid course. Still, this 
is oot iJwnjs the cfute, for Lu exo^plioii^d inHtJinces suuple meningitis uiny 
fvore btid to n joiiu^ child in thu cuni'iio of ttfenty-four hours. 'Vbe fover 
ID tlio Utter is, however, olwaifi* )>igl)i uiid the coiivulBious ato in most 
cues rL-p<^ated and general 

It would l» difflmdt tn confound tnbereidnr inciiinfritis nocompauied by 
retraction of tlio h<'fl'l ii-itli c*rf brwupuiiU fcvor. The hereditary tubei-cu- 
lar tcndcncv. the Ions prodromal period, the gradual ons^t of the illness, 
the more protrarted luid ihiu-acleristic miii-se, nnd t)ie slow intvnniltent 
poise, would sen'fl to distinguiiiil) the tiil»erciilnr discnw. 

En iaiautd uuder twelve nionthx old the diHertuo is vety difficult to de- 
tect. It may, Iwjwcver, be diMtiiigiiislied by clone nttentjon to the corn-He 
snil symptoms of the illness ; eHperiully if the ease oeeur in the midst of an 
outbreak of the malady. 

/Vo4p«wwf. — In all cases of cerebro-spinal fcvt-r tbo prownosis is very 
snious. The disenss is especially fstal to chiltlreu, and tJie younger the 
patient the loss hope e»n we entertain of a fsTOumble terminatioa to his 

In bnloM an arched and tense fontAnell**, wliich shows the presence of 
profuse ezodation as<l rr«l«ma, is n very gmvc Rymploiii. Id aU esses re- 
peated CODvulsiouH and signs of severe nervous ixdtation, such as violent 
and inccHsaut roiuitiug, uitcuite cephidnlgia and piun in the back, strong 
tetanic spasms ; ulso early appeanuiee of depre»Rion, eontinuous coma or 
ratun of the stupor after n period of npparent impi«Tem<»nt, and irregular 
lirewlhiug, are nil signs cnlcid»t«il to e:tdtv the gravest iippruhomdoQa 

T^rattmenl, — Tlie disease unfurtuustcly is little ameuable to tnratment. 
3b bU eases iee-lKigs should be applied to the head and spine ns long as tlie 
j>erio.l of excitement continues. \\T»ea svnjptoius of depression are no- 
tieed, the ice should be reinored, or siippfenienled hy the npplicstion of 
' ot bottles tn the feet, and the adminietnitlon of HlimuUxits by tlio mouth, 
slimes hot apphoationo relieve the eevci-e headache better than ooltL 
Tfao other spray luui been used to ihe occiput nnd hnck of the neck, and is 
Mid to be of service. Large dnsRH of elilorn! suffieient to proiliico signs 
of narcotism have been mrommcndcid. .AJl writfi-s, however, speak liiglily 
of the subcutaneous injetrtion of inoi-iiliiiL For ii cliitd of tlircc years of 

ont?- twentieth of a grain may be used, iind repealed everr oLe or two 
urs until some suusiile efieet is produced ; or four or tive grains of 
dtloml may be given by the mouth. 

D\uiDg proti-orted ronvalesL-eutv the iodide of potassium must be given 
to fortlwr absorption of Ibe exudations ; and iron and tunii'S, with rouioval 
lo a di7 brneing air. are of value to liatttea the child's recovery. 



or typhoid fcvci- is common in cliililnMi. A larg« propoiiioii 
'^'ftft eaaw /oi-Bicrly (li-MciilMxl tin "Itifnutilv itumiLt«iil Fever "were qo 
doubt vasen of lliis ilieMue. Furttiunt(>ly in yuunj; subji-cU typhoid (ever 
osiuUlj ratm a niiUl com'se. It would be, no doubt, too much ic nay thA^ < 
projierly treated aiid niirwd, no rliild ohnuld die of t.ji>hmd ;*bijt c*i " _ _ 
whi'n ])]ared from the be^iiiniug iind«r fnvounblecouditiouifori'eoomy, 
dentil in the ohild from such a cantw is veiy nira 

Infunts and children diiriiii; tbo first (our vt Svo yearn of life m-vqi k 
Busoeptible to the t\-pl]nid [wiKOii thiui iit a later a;;e. Perhaps, liowerer.l 
it in difSouIt to rc<!0|^Lzr> tlio discnHo iu taich youn^ Bulgects ; and it is not 
impossiMc tjint many asses of fcbriJe diAiTb(i''<t in the yonng child may bo 
oudtHs of tjpboid fL-ver wlucli luivc csciipud n.To^itiou, BoyH iin- more 
commonly aflfecrt^d than girls ; and Lba fever iMtemM t« atbick by preference 
prenonaly healthy chiltU-en, At any mte the patients who ore brongfat 
euileriiiK irvm Ihu disenae to the CUiliU'eu'ti Hoiipitahi are generally well- 
QOiiri)tlt«d. »tn>ii;^-luoking little peruoiis, with exM'plioDally good htstoriea 

Oiwmtion. — U ia uow well known that eutorie fever ariiieH tut tbe coq- 
8«qaouce of abeorptioa into the ^stem of a specific poison which is gen- 
erated by tbe deoomposiQg diHcharges of typhoid patients. It ia thei-efnra 
Inrgelf diiiti'jhiit^l by the eituuiationn from cesspoohi and foulty draiiw. 
Warm wontlior, whiob on^^oiiraffcs putrefHctioii, inerexisoH the provBleiice of 
the fc^-er. Dr. Murchiaon lins Hhown, from tho rocurds of the London 
Fever HoiqilUl. that ciines of enteric fever hefomo more immeruuii after the 
warmth ol tiumiuer, und lUminiidi in number after the cold of the winter 
months. Thuit. in Augiiwt. Suptember, October, and November, the fever 
nrerailH largely ; while in Fcbnittry, MiU^h, April, and May. it is much 
leaB frLHjuviitly Mit>ii. 'Whether thv ]K)i»on can he ueLemtetl du uoto is a 
question whioh baa been often debal«<l and on which opposite opinions 
am held. It seeinH certain that the decomposition of ordinary feml 
matter under onliiiary oouditiouH of atjuomihere cannot produw it ; but it 
in probable that Ihe aijccitic pmonn may be generated from non-apocifio 
orduio under estraordiuory couditiouH. At least, it is difficult tmder 
any tttlicr hypothesis to explain oiitbruidid of the ftrer in country villa^ces 
where the Rtrictc>i4t aeorch fnila to dit^oover any menoB bv which the diaeam 
can have been imported from without, and m which the same inaanitaiy 
state hait euaU'd uuchiin^ed for years. There is uo doubt that the di»- 
charges from the patient are hifrhly contagioua The diseaae cannot, bow- 
evw, be oommunicated by the breath or by emanations from the sldn. It 
ia held by Bome that the diaobur^^ Uiems«lve8 are at firxt oomputtiTely 
innocuouK. and only becowo hurtful aft«r putrefaction lias beffuiL 

Tbe poifiou enters the Hyuitcm by the mucous membrane of the lunga 
or of tbe alimeotot; canal. In most coeeo, no doubt, contamiualed water 



u the meiuia by which it is convcvod. Siiveral cntclemics of typhoid fcTwr 
to Londoo. cX ut« yeioK have been tmced to milk to which water coutain- 
i&g typhoid mAtt«r biul Iraen atMed. It is ah«o piYiliable that antrapped or 
UuUy dtaioa, allowing; the elUum of ceaspools rluu-Red with the specific 
potaoa to penetrate into a house, maj be luiotLcr mt^uts uf impnrLiug the 

One attack of trphoid ferftr does not neoeaaarily protect (gainst anoth- 
er ; aiid rupees arc ^"617 cniumon. 

3torfni/ Aualomy.—'TiiecliJxracier'ifitic letuon in ty]>hoid fever coiisists in 
s swelling of Uio twlilan- glandu nf Ihn tnnnli intoatine, of th« ft^iinat«d 
^mda coustatutiiig IVyor'a patchoB. and of the mmi-iilcric (jlands in omi- 
nvction wiUi them. Tlio snTllin<x ia u pure proUfumtion of thn rellutar 
■iiiiiiiinlii, which are aeen br tbu microacope to be iimch increasod in nam- 
her. Some corpusdeei become enltu-ged aiid develop smoUer c«lL3 mthin 
tbeir watts. The hj'pertrophic chuiit^ iu tbc ghuKlit bi'^ius early, jtrob- 
ably St tlie begiuuiujr of thii disuMLHo. aud ^iroceads rupidlr. It iuvulvex a 
eertatn Dumber of Peyvr'u patches. Theee are fully developed by the 
ninth or tenth day. aud form thick oral plates with abrupt etl^ea and an 
ntkeven, mammikted sui-face. Th^'ir roiislttcnoe in mtttcr than natiintl. ODd 
more friable. 'Hie aolitar}' glands may bo unaH'ii^U'd ; but they also often 
fwell ukI form small projections froiu the »urfsce of the mucous mcm- 
bmnc. After reaching tliuir fidl Ht/e the glands, in mild rnaeti, be^pn 
aIowIv to abrink. The newly prolifei-nt«d eclU undergo a fatty degeneration 
BS'l are abRorbed. The meaeutoric ^liuida nlwi diminish ill azo by the 
mmo pnwttti of fatty degimeratiuD, uod t^ntduully n'Kumo their former 

Id more severe caseii the diseased ;^1iuii1h, iiiHteod uf undergoing 
hMdthy resolution, take on a fui-ther morlitd notion. 8midl points of ul- 
camticni apjwnr on the siirfnre of tlie i>»U:)i. Theiio enlnit^R luiil unite so 
■B to form ftu ulcer which may covtr th*- whole of the diiteased i<nrface. 
Sometiioeff, instead of ulcerating at Fit>]mmt,(' points, the mncouii membrane 
vorering the affected patch eIou^Iih over a hu-jjer or smaller area and wp- 
anitM from the tissue beneath. If the whole of the patch hare been thus 
unooverod, the retniltinj; iiloer in oval, and Iidr iti« lonp;er nvia in the direc- 
tioD of tha OanaL Smjdlcr idcem may bo <.-ii-cutiir or ninuouii. Thv Holitury 
^uidK may nlao f-st ilu'ou<;h the samu iitocl-sh. niid leave xmrdl. niund ul- 
eera scnttered over the mirface of tlie mitcoiiti u]embraDi>. Tbe edgea of 
tbe uloem are thiok and Hharply cut, or even nndertniiied ; and llie floor 
ia formed by tbe KiihiuuoouR tissue, tht^ iiiusoiilar coat, or, in ba«l cases, 
merelv by the jM-ritoaenl ciireriii'^ of the bowel 

AfW A tim», n proo-esH uf rupiiir iu ttet up and the ulcent bef^n to heal. 
This favourable ohaogc seldom o«'car» before the end of tho third week, nod 
the pnRess of cicatri/.atioii ocrnpics a riu-iable time. Undtr favourable con- 
ditiomi it may be completefi in two or three weeka. but it is often spread 
over a lonfjer period. Tlie healing of the uleer ia not followed by any coii- 
tnction uf the bowoL 

The morbid prooeaa above described attackn fti*iwdally the glands in 
the neighbourhtKxl of the ilen-ciecul valve, and extentta xipwards for a viuia- 
blft distance. In Homo cutes the solitary glands in the coHnim and part 
of the aacendtug L-olon may be also aflocted. The deeper ulcers aro usu- 
ally in the lower part of the ilium near the ridve ; and when perforaUon 
occurs, it is by rupture of one of thene, whose floor is formed only by the 
peritoDoal coat of the intetttine. That, thin accident docs not occur oftcner 
ia dtw to ft looa] peritonitis having been set up, gluing the alTocted purt of 



tlSBASB 11 

tbo lx)n-iil to ;i iK-i;^hl)ouriiig nrcaii. Hiililren who die from this iliwAM'i 
die almtMt iuvariably iram iierforstion of the liun-el ; hut au uu(uTorabl«' 
emling tti enteric fnver is PonipArativcly it mre nceident in young fmb-J 
j«c-ti^, in whom tlio uolietULhy iictiuu in tbu glundH oftcu uto^ sliort 

Besideii the ept^cia] ohauges in the ghuids, the whole muooiu mem* 
bnme of the bowel in swollen niul relaxed. The enlarccd meeaDtenc 
^Itrniit A«idoin niippiinitc in the cliild. They uaually mpidly undergo ree> 
olution as kioii an the yroc9s» of repair has begun iu the tuti'^tijift. TImJ 
mloon is cnlarped nuu eoogeetetL It is daric rod in color and is mftflrj 
toftu naturuL TIte kidneya are aometimes oongeated. In tUl cssea of ty- j 
phoid fever tJie hingii ai-e the nent nf ratorrh, ho thnt the niurmiA mem-j 
urano of the air-tuhea iR ]-eil and (-on^stcd, anil the Lronchial glands an ' 

«&larg*d and tobcuIiu-. 

Si/mploTJUf. — Aft<;r vxjHiBure to tlif cuutu^uus poison there is a period 
of iucubation \'ari'iiig fi'Otii t«ii dayti to a fortnight, at (he end of which 
Uie syuiptunm of tlie fever begin to manifettt thetiittelTett Theee are at 
firat very sligbUy luarketl ; ao much eo, tJittt it is sometimes difficult to ttx 
the exact time iit uliioli the ittneitii began. In mottt cases, however, careful 

rttiouiiig of the iiaronts wiU euablo UB to d^tenmae the first day of the 
tvi6. One of the eorlieiit s>iuptonu is frontal hcadnche. It is com- 
mon to he told tliivt a i-hild rctume J from school Ka^*ing ho had n headache, 
tliat he looked jmle, was languid and could eat no <Iiiiner. Tliere is fever 
at tliia timo, hut th<' diild, not being Rupntoaftd U^ Iw really ill, in not. trentod 
net fui tnvfdid. Iii otlit;r vomcs Leadwiie in not cuiiipluintxl of at fint. 'Hie 
child is iiivrely jmle itnd lixtU'Si), with sumti fevei, mid ciiuiiot bo persuaded 
to eat For the first few days lillle elue eau be diticovered. The tongus 
is coated with a tliiu, white fur, t]iroug;h whicli red papilhe project Tben 
is often slight reLliie.-«a of the Uuoat. The bowels iu% either contbied, or 
one ur two Ioom.*, nither olTenHixe. stools are passed in tlie twouty-four 
houTK Tho ehild is drowsy, but sloops restlessly, although without de- 
lirium. He C1^neraUy complains of hts head, and often of aching pains 
about the body aii<l linihs. Sometinieit there is vomiting after food, and 
there may be trilliii^ opiataxix. Congh ia a more or less constant syinjv- 
tcm, but varies f^matly in ououoU Usually it ia ittsignifiamt at the liral. 
During thiit time. unleHH medical luutistunce he aunimonod, tlie patient lh 
Beldom confined to hin bod, but is dremed tn the tuoming an u^tah In< 
deed, in mild caaea, eluldreu will often walk conBiderable difttance.1 to tlie 
out-]iatients' room uf a liospitul, for the inuacular wtiakuosit is uiuoh k-sa 
markeil than might be anticipikled. 

So fnr, then, the sA-iuptouis are vi^ue ; and if it wore uot for the de- 
cided charartex of the pyrexia, there woidi) be nothing to help us to come 
to any ronrhision an to the nature of the illnesa It is only at the en<l of 
the lir«t week tluit inore clmiadteriHtip Bjmptonis are oliKCiTed. .Vbout 
the frixtli or seventh <lay the splocn bcginsi to enlarge. The organ can be 
felt to project inwar<l lowards tho middU^ liuc from under tlic rover of tlie 
ribit. Its texture ia Hoft, ao Hoft. iudeecl. in many cosea. that the enlarge- 
ment aim be only dct^ictcd by a pi-actised finger; and it appears to he 
tender, for pressure over itn substauoe uauolly pnxluovn »uiue manifee- 
tutiou of discomfort. Ttndonieaa can gcui-ridly be noticed at this time 
over the whole belly, and is uot routined lo the i-egion of tlie spleen. Tlie 
belly is now a little' swolku ; borborygmi are fretiuenl ; and ffw^Uug may 
lie ofleu felt on )>reasure in the right iliac fnttHO. Tliis. however, ia & 
symptom ae often absent as present. The bowels ore rehixed iu tiie maA 



; flw jfllknr odm " 
(Onufad Bpao. 8iaU, 
tlie *^»«M tbmn it is m i1h 

■ wah, onfy 

■t. and Am 

■UlU BH MCS ■> < 

o wn ta g ia at 

ooMUid o< 

The tieaJacba now qhmQt anlwde^ and the patiiHit begiBa to hat 
iliglit (IdiriiUD at ui^ibt. H> arts cmwlaaUy far drialc. but biIHimii : ~ 
any daspoatioa tu lake fuod. Hs notcMion at tlua tima is doll 
hoiTV, and be hes qmtlr oo hU ban, oAcd with a doll floib os 
cbeen, toldag litde aotm of vlut naoaeB aroBikd faitu. fi^ &e end 
tlw first nA tb« bt«r ha* iragbtn tta naximimL The cizu. ~ 
ahfaon^ gaoenlhr dir ia not ahana ao, aad tbciv m oeeaaonalh- a 
dencQF io penpiiatiaa. Tfaa laialiihn, ia qnjcfcenad, and Uw Inqac 
of tm palae ia tBcnasad Tben; ii no mnalant n la l ii» betaaen tbe 
and the beat at the bodr. Tbe pake bmejt be oaljr l ao d a ia t el y 
witb a bif^ tcmpttxtore. aod it* taiaiUtj aadargoc* In e p m A ' 

iTbua, Edith H . ■gnl Unrieea. gd tbe riglttit d^ at 9 KV. : |mln;W^ 

remirattoiL, 98 : teamentnia. I<l8.<i*. At 9 i-h. oa the loOowiDg' noaia^i 
pobe. 100; rp^rattnn. 36 ; taapeaatere. HKlH'i % the aid <tf tbe ' 
weak the niu^ l n oo ta mora tHuabhaoniic . and maj aaaanie toA 
ioeooetbataliineaSietiaa ia aaap eelad; bot onfy di; ibonebait 
baps oa occirinaal eoatae babUa^ ia bead abcmt tbe efaaat 

After file eighth da^ the brpbowl en^tioo abooU apftar. Ja ' 
ajmftom ia Bonetiniea ahaent ; bot earelul i an ie ct ioc of the 
iD*B, nsd baick wdl gaoaiall; diaeovar a few— it mav be oclIt atw 

{ tbe dbanetariatie qxfta. SomaliBee tbc-j caa be detected 
timfaa. Tbe laah appeals in the dorm of staall, aUcbtlr elenUad, 
ticnlar «pota of a deKeate roae tint, iwrjinf in aize from liaU a tine to a j 

.1 a half, and dia m pM ui ag eoiapleceh- aaitr pn mmn of tba fingM. 
:TUeii iiumbrr TBtica!, boi they nar br vrrr agt aaroQ a . Tbeas spots ooaa 
ODt ia aucrvnivf cti]^ eadi one hiiliin, two or three dajv. If aeant;. 
have to be smrrbei I fur with great eaie, aapeoallv when the back ia < 
for here, oo accouat of the geceni oooeeatkn'cl the surface, tbe; ma; not 
be nadilj eeeiL 

In thta thesaeood awekof theillBeBBaseBehdarpagBeatbeduMi 
become doIlM- and more in diff er ent He '» dxown- and aleepa „ 
the <laj. but at iiigbt maj be more rcstleask and aooetiinea be 
Icare hia bnd. Hi» weakaeaa baa now become more maikad Tbe [ 
uiek and feeble ; aiid towaids tbe end of the week rouacnhr tmnoe* 
twikhiags oa; be notired. Tbe beBj is much swollen and aaaamaa 
file chazBcteristic barrel abape. Tb« locMencaa of tbe bowd ooatinaeik or 
isrqdaMdlinf-oonBtipatioii, and aomatimes allhnnflh Uus ia rare in the 
dntd— tbe motioiu eoDtaiii blood. At Una tiBM tiw baart-sooadB beeooie 
faefafe and soft to tbe ear, and there in often a prolcm{::atioii of the first 
aouad al the aprs. or efco a soft natolic mamiar. On the ulLer hatiil. ia 
old etandioe caaea of eardiiu •Itw^ajw- & muniiur previooalj heard mar be 
lotit aa tbe neart's aetioo becomes rufeebled. onlj to reappear idien the 
atrmagth isiaatored. 

In the thitd week of the iUneae tbe fever nsuaHy bcf^a to diminiah. 
Id the mild cases the temperature beootaes natural as eaxlv w tbe fourteentb 
dsT. If it peraiflt, Its mean is lower tban before, and tbe morning tem- 
fnatuiT uiav be aliooet DomaL Tbe feebleuese of tbe patient ia now 
aofldentlj pronounced, bot a« tbe daya peas bj bis Hjmptonw become 
nan CanntnbJe. He grows lees hcarj and lethargic ; the swelling of his 

bolly dimmishcs; tlu> Kptern rctii-es under the ribs: diurrliaM, if it hiii 
prcvioudy existed, censes, uid the motion^ become more nntural ; and as 
the toii;^o cleans. Uu- child bcgiiiit to vliow sotufl diwntiHractioii at beiu;; 
stiU rentricled to liquid fuod. As tlie f«rer subsides, Uie pulse often 1>«- 
oomee intennittent, and is very soft aiid voiiiprv«MJble. \\lieu tbo ferer 
t» at aa end the child is left verj weak in the mildcBt cases, and he only 
slowly ivj^ntus lii» strength. In had caws tlie profitration is vprj great, and 
tbe Hiild lias to bo niii-sod Uirough n prxitracted poriod of oounUcHceuoe. 
Sometitues isdema, mora or l«fle geucrnl, i-s seen ns a AODMqitftnco of the 
iniiiDvt^rifllied ntate of ilie bloocL 

I'hc nboTfl is a iikntttb of Uie ordinuy course of enteric fever in tbe 
clittd. Thpre itro, linn-cTGr, many Toriationtt in Uie tiyuptoiaii, and it m 
doiuritbla tlioreforc Iv rt-fvr a^^iii to tunuv. of tUe piriijci|xtl pliouoiucna. 

7Tj'.' Digetliix Ort/au*. — Tbc luuguu iti mild (.vuoh rcimuiiH nioi»t ttiroasb*. 
out tlie whole conrBe of tliu illiituii. 11 Inis a delicnte conttug of grajruh 
fui', throiigb which tliepAi>iUa> are Been to proicct. The tip aud edf;es are 
only luudi^rntcly red. Tlurflt is often a nii\rkea Hyniptoiii, and liquid food 
is takeu reiulily tu Mitisfv thiH cnniti^ for fluid. Apiwlili- is (^-iiei-ally lo«t, 
but not in every case. A little boy in the Ea«t London Children's lIoapitAl 
CQniplaiiie<l to me on the sixtli day of the (Urease that be vras hiiii),Ty, 
altliougli liis temperature was then 105", and his tongue was tliicklr furred, 
with Bordes on tlie Ui>s. His mind wm qnite clenr. If thci H>iu|)tom« ar*.^ 
BOvers the tongue generally becomes dry in the courae of the xceond week. 
It may be fiaiiiretl a^^row "tlie dormjiu, and tlie lips may be cnw-kt'd and 
bladiened. Sore thrnnt is a ven- onmmon Kymptota during the first few 
dsjB, and there is some little redness of the iaiiet-R. Vomiting is frequent 
at the l>e|:;inning ; occuKionally it reciint liit<.'r and may tlieu giw trouble. 

Tlie HvreUiug of the abdomen iit due to itccumiilittioii of flatus tfarongb 
de4.vimpu»itian of food and inability of llio bowelu to expel their gnseous, 
contents. This loss of conti'actihly is the consequence of lock of nerve- 
power or of local injury from uhreraUoii. C<>iise4piently, if in the third 
week of illnaits there i» deep ulcemtiou of tJie intestine aud great l<odily 
prostration, the distention of the bcdly may be oxtrcmft The (unount of 
abdominal tenderness van c it. In Ihtiiuililebt casen it may be aboent. When 
present it may be lircnl, limited tn the splenic region and the right iliac 
fosao. or may l>e general ovpr the abdomen. It is sometimea a well-marked 
byiuptuni, the sli;;hteHt. touch being productive of great pain, and thix iu!i whcru there ih no rea.soii to siis[M.T't the presuuco of peritonitis. The 
bowels may bo oontincd tliruugliout, or lootie throughout, or eonstipAtion 
may alternate with a mild diairhcea. It must be remembered that loose- 
ness of the bowd» is due not to the nlceration but to coexiifting catarrh. If 
catarrh Im> in»igniticjLUt or abseut, the bowelx aro oot relft.xet1. An a rule, in 
ehildreu the looHeneaa iBuotextranDe and is eiurilT controlled. The relaxed 
motiouH al\ra^~fl assTime at one time or another the "pea-ttoup" ehnracter ;, 
they have an alkaline reaction and a faint ofYeniiive smell. Ha'uiorrbagV-' 
from tlie liowels to nuy aiiiouut is mro, but sniall black clots of blood luaj 
be BOinotuues found in tlie grumoua matter at the bottom of the stools. 

lite iirtiuT id at first scanty, with a higli dennity. It contatus an exoesri 
of nrea and uric aoid, but is poor in chloridcR. lAter it beoomm moref 
eopious, tlie qwciBc gravity faltR, and it may contain a trace of nlbomen. 
I>uring the height of the fever tliere may be retention of urine, with dis-' 
teiitiou of the bladder and teudemess over the pubes. Sometimes the 
catheter baa to be employed. Thure is no gnivitj- abont this symptom, 
auil it need cause no anxiety if care be takeu to cmiity the bladder by 


Tliv <UsU;Dtiuii is duo to low uf c-outni«til« power of tho iuuhcu- 
It tli^ii, A ^FMilly tli«>t(Midi>(l bltuldvr hv xudduuly aud ouui- 
iy 0m])tied <it lUt cuiiU>uti). the t>r)^u ouiitiTauts iiujierfeuUv, aiid a cer- 
' toiii Atnouot of air enters and causes gveaX irritatioQ. Ad obstioate cyatitia 
may \» ])roitiice«l in tKis way. 

The putse im quick ntn a nil«. but sometimes for a. timo sinks in n^iidity 
altboogb the f*ver continues high. Hie frequency of the pul8>e is not, as 
has already been stated, any tnistn'orUty ganio to the degree of fever : nor, 
aa talnn at a single eianiiuntioii, in it neceamrily any test of the wrerity 
of the illnem. 

l^ia- raiptraHoja are hnrried, and tlittro uiy be sLitrUt rliBtarbance of 
ttie Donnnl piilBe-respiriitinti ratio without any puluionnry cotaplication 

baing proMnt. ('ITiuh John H . a^d fotu- years, sixth riny, 1 v.u. : 

ttmpcrfttnre, 103 ; pul^'. ViO ; rcHpiitttioQ. 4C). If apnlmonAryoomplica- 
tion actually arist-, tht; hruathing increases in rapidity and ibero is liriiUty 
of the face. 

The idhn mar he moiirt: at timeB duriuff the course of the disease, and 
towai^lM Ihu end of tlie thii'd week, e3])cciaUy if the f«ver luia subsi<lcd, 
there may be copioiu 8w«ntitig. Suilnuiinit lh*iu appear od tlit- cliest. 
The ahuQdao(.'« uf the nwh varies ffreritlv iii differeat oases. It may Ix- 
Tvry ropioua or completely absent ; »ut tdese esti'enies bear no relation to 
SPVf rity or niildnesa of attark. It ia well to be tivrare that freeh riiips of 
TUKe-^wtM may pontinne to ajipenr for n weflk nfter tho to!ii[wmtiire has 
tUlen to the nominl Irrrt!. I havfl noticed this oil «pvo™1 occftsioiist. Tlie 
fvips is iiii]K>rtaiit. TUo child tteldum looka very ill in the eiuly tita^« ; 
and BVen lalt-r, uitlesa the ulidomiual mischief lie severe, it is exception nl 
for IiU fan" to near the onsioua haggnni look irhioh is ro common in many 
other aerious diaeowe, nml fomis such a striking fMitur^: in ttciitv titl>erou- 
loois. In onUnar}- cases the expression ia more stupid and listleas than 

The ejMviai ft-isw* may be affected. Deafuess is common. Epirtaxis 
is a frequent ^rniptom, and may be re[>eat«d a-;:aiu and again. The con- 
junctive look red, aiul t\i*- pupilH are lar^^e. The he»(Iii«1ie in cfaildren ia 
aeldoni very severe. It coa8«« about the oud of tho first week, when the 
deKrium besina. SoinetimeH cerrical neuralgia la noticed after the second 
ami evety morement of the neck may be oncompanicd by pain. De- 
is tlie rule, beginning totranlH tlw end of the timt week. Some- 

«• from this omifto oMfr children tiT to get out of Iwd and are noiay. 

iTolaioua may preccdu di-nth in fattd oisl-h ; but typhoid fvrur. unlike 
Bumj otlier (ebnle cmmplaints in cliililbood, in very nirvly iiMlicrud in 1>y a 
eonvalsiTe attack. Still, a fonn of diBcasc ia usually described in wliich 
the early syuiptotiiH are tho^ of high ucrvoua vxciknient. The child is 
convulsed aud h.^ luarkod delii-ium I have never met with a cam of this 
form of t^i-pboid fever iu a young subject- 

The {/^iKjeia, like m-vt forms of febrile movement in the child, in re- 
mJtteDt^ but the degree of reiaiasiou variftt at dilTerent periodn of tlie dis- 
ease. In the second week there is. as a rule, Imw viu-iauco between the 
moximura and minimnm temperatni-es than at an earlier or a lat«r stage of 
the complaint To tost the nodily heat wiUi any exactneaa, the tempom- 
ture sliould lie taken every three or four hours, Itoth <lay ami night. Very 
ialra eonoluaioiis may bo drawn from a iiioroly diurnal use of the thei^ 
SDometer, for the mercury i» not nocctsHanly at its lowest point at Ij <»* 9 
J.W., nor at ita lughast at 6 r«- 7 oVlttck in the evening. Again the mini- 
mum temperature may be non-febrile, or oreu subnormal. (Thus, in the 







etae of LHly F -- , Af*e<l eleren yenrs, a patient in tlie East London 
Childrfu'H lluspitul, tLe teiiiperature during tbe luOTQing hours boia B 
o'clock to iiaoD was subnoriuid Hfter tbe uuilb dny. It vna otien as low 
as UT', and yet lliis was au uiidoubtod caao of tyi)hoid fev^p. In Uie even, 
ing tlie li«H.t was IDS" or 103^) It is difficult to lay down n rule in a 
inattAr >irluch l» subject tn aiioli endleas rarie^ ; but perhaps tlie minimum 
temperature ia reflvbod more often betwoon the hours of 10 a.m. and noon 
than nt auj- other time, and the maximum shortly before midnight or in 
the early nioniiiig Iiouim. In ttie third week of tlie iliaeoae tite 1*6111181410118 
cener^y bt-coinc very inarkRd, niid tite minimum regiHtdred in otU'ii Uttls 
£igher tian a nonuti'l umpcratiir*. Tlii* is* ei«i)rciftlly notiot-ablo towordft) 
the fud of tli« week. 

Duriii<j tilt* tirat inv> days of tbe fever it is nuv for tbe child to be under 
skilled obRer\'ntion, and n meord of the leiiipernture nt thin timf> in not 
easy to obtaiu. (Jkxviaionally, liowerer, a bonpitaj ijatient, oduiitted for 
HoiuH clirnnif! c<iin|)liiiiit. Htckc-na of the dinetiBC, Hucb a caao occurred 
UU'ly in a bttlp jrirl, aged nine ywirs, who waa being treated for hip-joint 
di«(mito in Uie Kast London Chil(b"en"a HoHpital by my colleague Mr. 
Parker, imd mm l-nuisfiTrttl to my care on tlie outbrwik of tJie fever. The 
child, wboHe ti>tu]N.>i-Htur(? bad boon normal, complained uf headache at 2p.3i. 
Her t«iiipemture wanlben fouud to l>e 102.(>°. At 10 f.u. it bad fallen to 
100". On tbe eecoud day, at G jlU., it was BQ' ; but rose gradually, l;«itigj 
taken every four hours, till (! p.m. when tbe thermonietei* uinrked 103.2° 
It tbi'Q follnuddeulv l4> ftir at 10 p.m. On tlip third ^\ny nt 10 *.m. it waa 
102,-1°; at 2 p.m., 102.4 ; nt6i>.M., 11118 ; at 10 i-.u,, 102.6^ After tbia 
it varied lietwoeii 101" and lOS.!*" in the twouty-four houra, until the] 
middle of the third week wlien it roue rather higher. 

In a cjuia kin^Uy cnnunuuicjitcd to me by my fricuil Dr. Gee, tbe iam'- 
]>ftnituru ui u Uttlu girl uiiilur hia care was 103" on the lirtit tbiy at 2 p.v., 
and at 10.30 km. ilwnx 103.(1 \ 

Id a ease published hx Dr. jV^ihby, of Mftiiobest«r — a little girl of niiM 
years — tbe lemi>trature was 100^ on tbe Hret evening. On the »eooQd 
day: momiug. !l!f.4'*; evening, 101.8'. On tlie third tUy; uioniing, 
lOOLi" ; evening. 100,4'. Fourth day : morning. 101' ; evening. 103.4*. 

From thene three cues it appears tlmt then! may be great variatiooa iaj 
the degree of p.^Texia at the ucgiiiniug of tbe disease. lu tny own case) 
tbe teiiiperHtiire I'eacbed its height on tlie second day nt C p.m. ; butdur* 
ing the Hrst two days tlio varintioiiii were vniy great 
■ The duration of tynihoid fever is from foiiieen to hvcnty-GUC days aa a 
ru]p. The tempcraturo nttvn falls iu yoimt; sulijccts at tbe end of a fort- 
night ; and Homelimes, nltboiigh very riLrely, may Iwoome normal at a atiU 
earlier date. Tho possibility of so short n duration for the fflver has been 
doubted, but tliat it may ocuur in proveil by Lhf foUiiwing case. 

A httle yiil, aged nine yews, was perfectly well on September 14th. 
On tlie following dav, tbe 1.5lb. she ooiiiptniued of ehillineBS itnd frontal 
headache. That uight the akin was noticed to be hot, :uid for the nei 
WMk the child was apathetic, inngiiid. ami ferensli. compLuoiug of faeai]-* 
ache and ab«lomiu!il ]>ain. She did not vomit, aud there was m> bletxling 
from tbe noBe. Tbe cliild was seen on the 22d. Her temperature wu 
then lO'i^, and a n^sp-spot was notiiMMl on the abdomen by tbe be 
BUigeon. On the 2:)<1 (ninth tlay) she waa admitted into the hospttaL 
The abdomen wns then inodoratolytlixtendwl ; thesplaeo could be felt two 
tingera'-tnreadtb Im-Iow tbo rilw ; no spotn were to be seen ; tho temperature 
in the evening was 102.6". 


After this dnle UiP tcmperalure was never hiRhcr than iW and a fraction ; 
the child looked iitttl es|)Tii>«!u>(l hart>elf ns well ; the spleen quickly retired 
under the ribs ; the Appetite yfaa good, and the patient «oiiij)taiued much 
at bein;; restnnte<l to ri<|»id food, On Octolwr Stu, the teiiipumtiin; liftriug 
b«ea Dormal for twelve day* (witli the esc^ption that dq one ocuasion, in 
tba ooarae of Sepwniher 27th, it ro)«e to ld{).3^), nnd subnormal for bis. 
Hut child was put uu ortliuAry diet Two daya aftervrnrds the temperuture 
rose to 102°, tbo spletn be^run to enlHTge ; row sj>ota appwirpd on the al>- 
doiDen ; and the ptUient p(utii«?d IJirnui^li n woll-miLrlti^d reliipHo of typlinid 
fever wtiioh lagted tbe usual moo dajB. 

In thijsOMe the onrly iscftntionuf thopjroxia Boomed to cxclmlotjiihoid 
ierer ; and as the tempemtura oontinned low, a tnea-t diet was tUIoiTed 
mder the idea that our fintt tmpreanon of the illnoea bad been a miatakon 
oae. The pminpt ocrurreurb of a typicul relapue, howorsr, at ouca re- 
DKired our doubts as to tlio nature of the primary aitat^k. 

la some cases the tomjifmturo reutiuua hi^fh after the usual time of fall- 
ing at the end of the third week. In many cases Hub is due to progressiTe 
oloerative enterituji Indeed, Dr. Gee laj» it down a» a rule that when 
PjTCXia and enteric i-iyniptoinR laflt longer timn twenty-six daya thia ia tljo 
euiie of the proloofpition of the dtscAse. He also eug^gsste that "vubin- 
imnl relapau " umy Im an oi»^oaa] t^oot in producing the mmu reeolt. 

Death from the intensity ot the general diAeaae, bo common in the 
adult, in very rare in early life. In very eEoeptionnl caaeti, however, the 
dian-bo^ may be exoeesire ; the teiiji>eratare may riae to & high level ; the 
pulse may be fretiueut, fc-«bLo uud dirrotuiiH; the abdomeu may he 
•woUen and tytnpauitio ; the oliild in delirioiiH, then cumattwe, and dies 
•ith a tempomture of 108' or 109 . Still, althongh this tj-pe of the 
disease ia occasinnally mt^t with in the rhilil, it must iinppen to few prao- 
tilioneni to meet with hutIi cmtoL When diildren ilie from tyjilioid fever, 
they die almost iitvnrinbly from perforntinn of thi? bowel and genern! jwri- 
tocitta. Thu rupture occurs in tbo floor of a deep ulcer and takes place 
quite Hoddeiilj. It ia foUowwl by an escniic of Rn» and of tlic fluid con- 
teots of the intestine into the peritoneiil cavity. Immediately, the abdo- 
men beeomea diatended, and there id intenae pain and tendemeHB. Some- 
times there in vomiting, but ttiu patient iu any case sinks into n fttatu of 
ooUapne witli duf«ky haggard face, cool pui-ple extremities, nud 8iuftU rapid 
paba .Uthou<;h the surfaee of the body feels cool, the internal heat re- 
mains high (103-104°), The reflpiratioD is thoracic. According to Nic- 
meyer, sudden diKippenranoo of Uie liver duhiesK, on account of that 
oi^an being separated by the tymimnitis from the abdominal wall, U one 
of the moot oertnin sii^na of peritonitis from perforation of tbe 1)owcl. 
This aocident doee not often happen iTcforo the cud of the third week. 
Vhtn the pMitonitis Is general, it is tdmoAt invariably fatal, and death is 
sometimes preceded by an attaek of convulKionft. If the intestine have 
bMn previouslr mntt«il by local inHiuuiuntion. rupturu of the door of tbe 
nicer may not leiHl tu such Kcrioiis L-onHequenccM. In nucti a com wlien 
parforatiou oceurs, the estmvnaated oontenta of tbe bowel remuin eurysted, 
sad tbe reeultinff peritonitis l» limited to the neighbourhood of the leeion. 
Id bbe end tl>e anacess thuit formed generally mokes its way to tbe aurfooe 
and discharges itut contents at some point of the abdominal walk 

Other oom]>1trations wliich ^ve i-iee to discomfort or danffer are : — 
jpflsmmntiwt of the parotid glaud, or of the middle ear, bronchilis, plcurivy, 
pneomonia, and catarrhal pneumonia. In one caite — a bny aged thirteen, 
under my oara iu the li^t London Ctiildren'a UoHpita] — an exteutdve 


plutM pwruwrditu uriNn duriag tba third wock of itlnow, BodsoM« 
rarely occur uolew tlio child is greatly roduccd hy pratr&otcd iHomb ; but 

boiU aii<\ a.haci!»ie» tats uut uucoiuiuou. Ulceration of the bujnx has been 
deHvribed, but luuKt )x< vory nur«. Auotlior rare cotnfiliation is tliram- 
boaia of the veins of the luner extratnitiee. 

After the fever bfw Atilmdcd, the tempenture usudly rsmutM mbnur- 
tnul for eoiuo tinio. Xot unfixxiuentlj, howorar, sffer uie Iadm of a few 
(.lays, the child ia tiottcv<.1 to be f«vonsb again. Tliou eeconuary pjreiuas 
nre vei-y common. Tber may bo duo to u xval rclapee ; tn the i}reeeoce 
nt some irritAiit in tlie Iwcvel, mich aa hardened fooal mattM* or undigested 
foofl ; or to soiufi febrile complicotiou t>rhieb maj ba oallad necidental, m 
aa ab8COB& 

Real reliqwea are far fmiu tuicomoion. They begin after a variable ia- 
tcrval — four or fivo linyti, or longer — and seem in many caaM to be detar- 
laiaed by iujudic-iouit focdiog in the etag« of early conraicitoenoe; Tbe 
tempL-nituru rises ; t\to aplvvn a^iia anlaiigca ; bvtth spota appear ; and the 
bowela niay be n^^aiu reLaxtxL Untally the mnptoma are milder than in 
the primary attacic aud last a shorter time. The aTeroge duration of n ro- 
lapHe ta nine tlaya. 

CoDstipation and the irritation of the bowel by Iiard fecal masses in a 
oonitnon eaoso of soeondary pyrexia TIio teiiijwrattiro tmoally rtaea to 
102° or 203°, bnt may be lugli«r. AVhen the initaut bos been remored by 
n copious injoction, the prrexin at nnce di»uippeiir8. These attncls of t«m- 
pttmrr elenttiou of tnmpemtiiro may renir again and again iu the couree 
of conTOlcitcionoe, but iiCfTil ocmsion no anxicti'. 

CoUTttluticcnt-o from tyjilioid tvwx ia otUin tedioua The child ia left 
veak and low, and nutiitiun may not at once be rtveslablitihed. It is n r»- 
mai'knble fact— -to irliicb nttcutiou Iielh been dniu-n by Dr. West — tltat the 
poiiunt IK i^nfcefalod iiit^-'Ucctually as well as pb>-siraliy by hia iUneas. For 
some weeks after the fever is over he uuiy reunun dull and indifferent^ 
taking litiln iiitf-rr^t iu pursuitaandaJDUaemeuta which formerly delighted 
liiia. A child vt three or four years of age may seem to have forgotlcu 
how to talk : and tlio iwrsiatonoe of this mental veakness for soiut.- time 
nf1«r the Ktxcuji^lb has been restored is often a cause of great anxiety to the 
patient's fi-ieiida. Such anxietr is, however, grouDdloes, for the re'tum of 
mental tone at no long interv^ may be confidently predicted. 

These casos appear to be due sometimea to dpfedive action of the kid- 
neys. In one case wliicli c»rao under my notire tho cliild (a boy of seven) 
viAA left after typhoid fovcr in un apathetic, stupid condititm, taking no 
notice of anything, and never spvakinj; crcu to make known his nstiind 
wauts. He ap)>eared tn tie in a stnte of great wcidmess. and had oceafdoii' 
ally n«n-oti8 Roiziirejt in which be became quite atit); and aeemed to he un> 
consciouH. His skin va^ dry and exoessivoly ini^lnjtlic ; there was uu dis- 
coverable disease of nuy of his or>^na ; his tfiiipentture wits subuormal. 
At first he bad a slight truce of tedi^niii of the legH. but tbii> quickly passed 
off. UiM urine never contained albumen, but its t|UantitT was amalL For 
n long time the boy pa.'ued no more than ten or twelve ounces in the 
twenty>four liuurs, with a specilic gravity of l.tHS. The excretion of aoUd 
matter by the kidneys was sio evidently deficient that iliuretica were or- 
dered, and (be boy waa forced to take a larger quantity of iluid. Under Uiis 
treatment he soon liet^an to mend : his urine became more copious witli a 
higher density ; the elasticity of his skin returned ; his nervous ssixoros 
ccascl : and hin stri'U^tb. mental iiud boililr, rapidly improved. 

A chdd witli any diathetic taint miiy have Itia predisposition strength- 



bv his iUneea. Tabcrculous aoinetimes occurs ; uiil scrofulous ten- 
,y ttceive a distinct impulHe. 

18, — Oa account of tbe nef^ataro oharacU-r ol tlio e^-mptoius ut 
ing of the Lllueas, euttuic forer is oftcii ilifficult to nxognixo in 
the enrl; stage ; and oveu st a later peritxl the nature of the oomplaint 
must be aometiiQQB a nuitter of doubt. Still, the dlBease is one of such 
freqneut oocurreoce tlmt we should lUwnys reiiiemher the possibility of its 
h>-iii^ preaeot. uiul abould nevor omit in a doubtful case to mule inquiry 
Hs to the exist^ncoof the disease in tho uoif>ldKiurhood. Th« be^i^inin^ uf 
taeafdefl^ scarlatina, and nu-iola is tiuthcicntlv distinctive to jH^vuit their 
lifLUff confoanded nith ihU disorder, and mnrnover, the ahflence of the 
^!«)Ctlic cmptioiis of tliem complaiata will itenro for thoir oicluaion. A 
high temperature on the «ecoDd day ia a ohild who suffers from nothioi; 
but an ill-^le&ned mahtiiio is enough to jfive ^oundn far eospicion. If, as 
the da^ pAss, no otJier symptom <l«veIopH ibtelf, our suspicions are ma- 
terially Htnnf^ened ; atid vlien at tlio end of tlia VfecV, enlargement of 
the spleoQ with swcUiug and Leiitleruesa of tlie belly can bo detected, 
eipecially if there is also looHenesH of the bowels, there is Imnlly room for 
finther heeitatian. 

Acute tuberculosis may present a rery close resemblance to enteric 
fever in the child, espeduly as we soraetimes see a rose spot here and 
tbm on the bodies of tabcKolnr cfaildreu which, except for being nitlier 
Urger than the typhoid )!pot^ and perhaps a little less deUcate in colour, 
may be, and indeed has been, mistaken for it. In both tuberculosis and 
enlsric ferer dianheaa may be a prominent fieature ; in both there is fever ; 
and io both the geoeral aymptomi* may be very indctinite. Often, in these 
caam w* cauaot docddo^ hut must tvuit for thuo to rdteve our uucL-rtainty, 
Bat ID many cases we ntoy venture upon nil opinion, for in tuhcrou- 
loau the absence of niiy dognitR time of t>eginning ; the leas elevated tem- 
pemturc, the bodily heat being rarely higher than 101'^ in the evening ; the 
distn^ttied expreasiou of the patient ; the itbaence of indatiou of the ahdo- 
meii, and the iintiinil nxe of the Kpleen are ttll potiita in which that form of 
Hloeoa differs from »vpliotd fever, and may serve to help na to a coiiclusioQ. 

Sornetiuiee enteriu fever may be mislaken for tubercular meningitia 
The illness may begin witb drowsine.** and sickness; the lieailaclie may be 
seven and ptovoko cries from the chilil such ns are commou tu the intra- 
onaial inOammatioD ; th« vomiting mar persist, and the bowels may be 
ofaotinately CfHifinwl Ktill. the belly in diatcnded, and has not the doughy, 
dooeid condition of tho porietes so peculiar to tubereular meningitis; the 
poise, until c<^nTaI<!»ccn<3e twgin^ is not slow and intermittent ; tlio rr^pi. 
ration is not sighing ; tho pu]nla do not beeomo uuc(|ua], uud tliorc is no 
squint. The temperahire, toa is much higher in tho case of typhoid fever. 
lor in the earlier stages of tubercular meiiingitia tlie b<xlily beat is seldom 
greater than 101 '*. Ldter, ncme of the symptoms of tbe third stage of tuber- 
cular meningitis cao 1>e discovered. 

Acute gastrit! catarrh, accompanied as it is in 8«>rofuloiis children nith 
xia, may cause some embarrassment, but here tho tempcrnture is less 
_h than in enteric fever, and does not undergo tho same alternations ; 
there is no distention of the aUlomen, and no enlai^ement of the spleen. 
Htill. in many cases, before tlio fever mihsiideH on tho ninth or tenth day, 
ve eaoaot uy positively that wo have not to do with tho more serious 

When the purging is aevero the case may be oonfoimded with one of 
tntemiDatOTy diarrhoBa, and it is posrible that in young ohildrcn under 



r foar ywa* of itffo tlM mistaltc is oftMi aude. I tliinlc, Itovever, 
at the shcwber oounie of a non-Bpocific miioo-eateritiB, the stneritj' of th» 
purging from Ibe tmi, tlie liaggani aspect of tlie patient, and, if tlte dis- 
enite last long etiougli, the ahnence of Bplenie enlot^^ement, of tbc rosy resb, 
and of t]]u BigtiH oif pultuoDarr catorrli, abotild be imfficicut to furni&b a 

Simple or tiibprcular ultwratioo of tbe bowels with enlargement of tha 
meecotehc glands tnar be also tnistaJzen for enteric fever. But in th<»o 
disorders tlic i«raperatar« i« Ipas eleyated than iu tv-phoid ferer. and the 
liJKtorv of the illiicw ix very dilYerRnt Tlieir couiw. also, is wry inuidi^^H 
longer. Tbor? is, brMdt^'fl, absooco of th<v rai^ih, of the mileojo ealArg«iii«n|]^^| 
(onleSB, as may happen, there is tulxin-ular disoBCO of^ the spleen) nod of 
tlie idgQa of pulmnnarr Prttairh. Fiirtlier, in tubercular iilreratioD tha 
lungH are genorally t!ic iwaf. of onnoolidation an<1 the enuteiatiOD is COtlveiBtt. 

Chronic tubercular pL-ntonitis, wiUi Ha rouj^h honh ddn, its pniidi>- 
flactuation, and the coKouuis maHsi-» to he ftlt on palpation of the BouomeQ, 
OBO Bcaroely be confounded w-jtli enleric fever. 

lAfitlj, tlie difrtdnction between tj-phoid and typhus fererg is now giiffi- 
cioutly fMiibliithod. lu the latter diseaiu^ the oiiftot is always abrupt, the 
rash, abuutbmt and quite different in its appeanttR-e from the rOHy typhoid 
Hpots, appeara ou the fifth day ; tbe ttu^ m dusky : drowsineBa and stiipor 
are early e>-mptoias ; and tbe eod — whothor favourable or tbe roverta! — 
comes in a sudden cmia. 

Prognosis. — It has been already said that oompamtiToly few children 
die from this tliscaw ; but Kmnll as i« t-he poroont/me of inoi-tality, it ia 
greater than il. need be. This ih piirtly due to the way in which tlie 
disease begins, and the mildneHs of Hh early symptoms making diagni 
doubtful. It is also owing in port In the cliniscter of tbe early Hyinptotn% 
and the abuse of domestic remedies. A child ia found to bo poorly* 
vomits and complainw of headache Immeiliatt'ly he in treated to a 
of ooHt/»r-oil or other aperient ; and us the symptuma are not found __ 
be reUevt'd by tliis measure, the dose is repeated, perhaps several time* 
Tlic'i-o is uo doubt that sucli treatment i» excessively iujurious : and iu 
hospiltd practice the cai«e8 which termimite fatally geuemlly have a liistoiy 
of active purgation having bf«n ad4^>tsd before admJasioD. 

However aevere the (tymptoms may be^ we may look forward bopefullj 
to Uie issue prorided perforation baa not occurred. Children respond, 
well to Htimiilanis in typhoid fover ; and a patient wlio is seen i^upid 
and droway and profoundly dcprciwed on one mit. mar present a very 
difFerent appearance on the nest under the free use of brandy. I tliins 
even muscular tremors tinvc not tlie same unfavoumble meaning in tlw 
child that they bavft in the adult, .Still, if the tongue qniTers when pro- 
truded, the lower jaw trerablc.s wlien the mouth is open, and general 

lulousiiess of uiovenieiit in pron'>uuced. we have reasou tu fear tW 
enence of a deep uleenitive leHitm in the intestbie. Our B]mreben8io: 
are stxcnglbciied tf at the same time the belly is much dieteuded, and tli« 
temperature rciunins pematently elfvaied after the end of the ttiini week. 
In Buub a case the danger of porfomtion is imminent 

If perfomtioD take place, the progiions is most grave; but cren in 
tliis strait deatJi is not abaolutely certain. If the ooUapee which followa 
the est ravasatioR be quickly recovered from, even altboiigh comdderabl* 
'^rmpanitis, pain, and tfindcmepa remain, we may hopo that the pcntonitii 
'lasoeen localised by int«etioal odhcsions, and tliat (urtbcr impnnremeiii 
nay take place. 




TrealmfrU. — In every case of typlioici ferer, if there is any Tcaeon to 
-suppose that the dinease has lieen contracted in the ItouHe, tliu dmius 
should be tliorou^lil; examiofld at the eitrlt«iit opportunity, and even- care 
iDtni be taken to promit tL« entniuee of aowor-i^ into thi> paasagetL 
An aoQ-pipva aboukl bo ventilatod : wnsto-ptpcs ^ould he cut uff frum 
direct oommuuicatioti witb the sewers ; cisterns siipj>)ying vrater for 
drinking' nnd cooking sbonld be raitiml^ nepamtcd from thotie whose pui^ 
pose is merely eauitary; and the water ittx-lf— unless its purity be nbove 
Buspiciou— should not bo drunk without hnying previokuJy bevii boiled 

TIm treatment of tpphoid fever ooDsista tntunly in carefiU and judiciooB 
narsin^ Sir WiiUam Jcuaer baa iuBieted tttroiii;ly tipoo the abnolata 
DaoMnty in this ooaiplaiut of perfect rest. The oliild Hhnuld Iw ooiifined 
to bed fit onee, and if th(< attftcK )uu occurred at a diKtan<N:< from hiu Lome, 
it is better tLa.t ho should renuin where he in, than run the risk of in- 
creasing the neverity of Iiih illnet^s by tlie fatigiiea of a removal. Fatigue 
not only exhaatrts ner\'«-pow«r, which in idready rodiiood by the fever, Ijut 
it abm inercaaea dftstiuctiOD of tissue at tJio Haioo tiin« that it chf-cka climi- 
nation hy tbc uxcretorr argann. The bedroom should be h large one, and 
tbe air must be kept ah pure as possible by judicioua ventuation. Its 
temp er atnge should not be allowM to rise abov« G5'. Hie patient lihoQld 
be Uglitly covered and not ovcrloodud with bedclothos. Tliure is, how- 
ever, on* precautioD wbifb it uf expedient to tike. As in all etuu's where 
tiw tnooous meuibnuie of the bowebi is the seat of (.iitarrh, dami^l i» the 
efas|)« of a flannel bandage should be iipplivd round the belly eo as to 
amnd the risk of chill. All dittchargen from tbe body must be at onoe 
dittnfeet«d bafora being remoretl from the room, atid linen, t-te.. twiltHi by 
■oeb diaduuVM must be subjected to the same dittinfecting prooewi before 
being washeoL If there be reason to BUhppct tlie j>iiritT of Ujg woU;r-sup- 
Illy, none should be used for drinking purpnsfs witlioiit prrWous boiling 
tiiid filtering. I'hiR, however, the child mny \w rIIowaiI to drink without 
titiut, provideil too large n quantity he not token at oucv. A free supply 
n( water assists the dcpunititig action of the akin, kidncysi, and hings ; but 
distention of the stomat^b by ton mudi fluid is provocative of nausea and 
Hatalenee. For tins reason effervescing drinks are to be avoided ; tbey 
are apt lo distend the stomach and cauHct uneuiriaeHa 

Tbe <|i]estion of diet is a very imi3ortaiit ona The old plan of " atarviog 
tbe fjivor" and R«du('iug tlie ]iaUent has Ik^su furtunalt'Iy abandoned, but 
ir« must not fly to the ojipoidte extreme and overloiul the stomach with 
food in tlie hope of supporting the Htrengtli, liowever digestible and well 
seleoted the food may lie. I<'nHnfu^oouti ninttei-H, on aecnmit of their ten- 
duiey to ferment and form acid, are liottor avoided. IVuit for the same 
rvaaon is out of tlie qucation. It is belter tu rt.>Htrirt the dii^t to went 
brotba nmde fresh in tbe Iiouhe'. and to milk. Tbe broths may hv flavoured 
with te^etablta. but munt be caivfullv ntrained. Tlio milk should bo di- 
luted with an equiil (juantity of barh-t ■\\-ater, so as to split up tlic cm-d and 
prevent its coagulating in the* stomiiL-h in largu liiinps. Masses of hard 
curd an a fre([ueut sourL-e of irnlation, nud may excite rrstJeHsnesH and nb- 
dominnl pains. They may also, perhaps, increase tbe dinn-hcta. Tbo 
<|aautity of footl to be given at one time should never be left to Uio dis- 
txvtion of the attendants. Nourishment should be administered in pr»- 
Kcribcd doses at regoliir intervals — ^thc quantity and tlie length of the in- 
tarvabt to be decided by tlic age of thv patient and the facUity witlt which 
tbe meal can be digeatetl. Xauscn, restleasnoeB, excitvmeut of pulse, in* 




creiBe of Itctut, anil [lushing of face, ore aigiu that tho lUgeatiTe orgatm an 
beioR laxecl beyouil their power*. 

Tlie question of Htiniulntioo is eloselv allied to that of food. Stintu- 
lante uiuat not be jtivon too earl^r. They are useful to strengtben the ao- 
liou of ihe heart «nti iiicreaA« nerve-enrrgy. but are seldom required before I 
tbe eud of t}i» second or l>ef.nniii»(; of tlw third week of tlie dineaw. Gv«n| 
tbes, tbey shoukl bo only {^ven in scrom Cftsm vhoro the honrfs MtioQl 
given sipm of failing, ami them in marked delinum or Knot muacaljU' pron-i 
tnttion with Ireiuor. Tremor, "out of all i»rii[)ortion to other BigtiH of ( 
iierxoiis pro«trft1.ioTi, ■* is, in tlie opinion of Sir William Jeoner, evidenc* I 
of deep dcstructiou of the bowcL lu thci<<c ctufca uIcoLol 18 of tlio utmost ' 
value. The sifpis ooaooctcd witli the heart -n-hich may be t^ikun to indicate 
tbe neoensty for Btimnlatioo are ditntnution or mipprewiioi) of tbt> tnipuke 
with feeblcnees of the first sound. The effect of stimiilation should be 
carefully 'wiitchcd. If tliu f«ver iliminisli, Miti toiij^ue iiml ekin get or re- 
BMun tiioiMi, th» piils« and respiration becom<> alowt^r aiid fuller, and th« 
mind cleoror, \t6 may know that we hare benclit«d our patient. If, ou the 
oontiorr, tbe temperature rise, the heart's action become feebler and moie 
firequent, the deliiitmi iiicrr-ase, and the child get restlen with inabiUty to 
deep ; or it be become duller and neem Hiniiin^ into a comatoso »t«te, we 
may ooncliide that alcohol ift nctinp; injuriou«Iy, aod that it must b« diaoon- 
linued or given iu timallcr quniitititMt. 

lu typhoid fevei'. aa in all other febrile diaeases, it in important to ■ 
watch tiff t*?inpemtiiro and rejjulate it If, for iuHtaniw, with a temper^j 
ture of 105', we liod reatlessoess and excitement with waJiefulness, th« , 
obild ahoold be sponged over the wliok* body with l«]nd or oold water. ' 
Tim lessens fovcr, cnlms irritalnlity, and indueea Bleep. More than tepid 
or eold Bpongisff is seldom noceesary. If, bowerer, thc> tempemtnre be 
not of^weciauly uiwwed by the epou^^ag or rise n^oin immediately, the 
child may lie placed gently in a batli cont^ning water at TCr, and b^ kept 
imiiu-rsed for ten, fifteen, or tw<>nty miniitoii. It is well to r/intinue the 
bath until distinct Hhiverin;; hiui bevn produced. Tbe child must be tbon 
removed, wiped dry, luid retiimetl to his bed. A Htiuiuliuit may be given i 
at tluK time if thought desirable. Tbe cool bath should not be lued unlcuj 
there ia a real neceesity for it. Children can bear a continued hi^ tem-j 
pemture better thou older persona ; and if there is a daily remiaaioD. at ' 
occurs in mottt cosmi, mere spon^n^ will do all that is reijuired. 

Delirium is liCAruely Bufiieiently violent iu children to require treat- 
ment — at any rate in ordinal^ caaee, and h6a<lache ia seldom a trouhle- 
Bome aymptom. If it tdmukl lie so, it in uniially relieved by rold api>lica* 
tioiUL sWpIoiftmietw may be geuomlly reliovotl liy ttio tepid euuDj^'iug 
above referred to. If iieceiwnry, n dmii(:,'ht ivmtaiuing broaiidc of potoa-i 
aiuin in combination with cUlonil miiy be t^iwn. 

I>inn-hcBa may aometimes require remediea In every case where the 
stoois are too frequent aiul watery we Hliotild esamine them forcur«l (^ 
milk. If thirt be present, the amount of milk tnkeu at one timu mmtt l>ti 
reduce(L Wn should also take care that the cliild does not drink lluid in 
excess, and if necessary hia drink must be given to him in amaller cjuan- 
tities. When drugs ore required to arre«t tbe pui^iu^, chalk au<l catechu 
should t)e given if tbe motions are frothy. If they ore strongly nlluUiue^ 
dilute sulphuric acid is most usefuL In the later period, when there ia 
ulceration of the bowel, bismuth in large doees is indicated Hieroorrliftg© 
from tlie Itowel-s i» a conii>anitive]y rare syinptom in tlie child and aeldom 
Tvquirea treatment by dnigH. If necessary, IJowcvej-, gallic acid and dilntp. 



SQ^liuric ftcid Ta&y he ndminiRtored vilb BUoU dosfia of opium. la such 
a case tlie rliUil BbouliI uu no account bo allowe*! lo raise Iiimwlf rrom 
the reciiiii)>ent posture eveu to relieve the bliuldnr nr tha bowels. It is 
mil also to give liim liis food in Btnall quanlitieii iukI in a concentrat«d 
team. StroQK l>e«f-«s»6iice, well iodd, and uood meat jcUy sbutUd be em- 
nloyed ; and but little lailk sbould be allowed, for fear of irritating tbe 
intoatiiK with liunpe of cunL 

If peTforation and peritonitis occur, opium sboold bo g[rv«o in amoU 
doam, but frc«|Uciitly, so fu tn jmHluoe some of the early [dijri(4ogical 
cflecU of tht drti<;. Ktioli an dmwaiuofia aiid teudeucr to contraction of 
inpils. In lOT exi>en<>nc6 opium is in eucb cases of small value unless 
[niahed to tins extent Tlie l^elly »Uioul<l he also smeared vnth an oiut- 
ment composed of et^ual p^rta of extract of belladonna and glvrerina, and 
be kept 4V)vere(l with hot linseed meal poultices frf't^uotitly rciien-ed. Ttie 
food m tbese cases slao must bo eoncentrated and (^vcn fi-txjuentlj in iniiall 
iiuantitiea Bnuidy and egg will be requirpd to HtifdAin iJte tttrrngth. 

Daring the iwriod of con'wJeaoonco careful (ot^ding is still rew^airy, 
for 6rn>rs in diet at this time arc a frequent cause of relapse in tbe fever. 
I hare alwaya made it a rule to allow no aolid food until ten dayn haro 
p— od after tbe &na1 fall of temperature. But even tben the usual diet 
oi health should bo only slowly returned ta 

lu order to pnrvent rulitpHca Immorman recommends, in addition to 
tbe utmost vigilance wilb rejjanl to diet, llie daily aduiinistration of sali- 
cylate of soda in full doHea ; l}«{Tiuniiig directly the fever sulHudi>ii, and 
continuing the use of the drug for ten or twelve dava Tbe after aniemia 
and weakuesH must he combated by iron and good food. Change of air 
to a 1I17 braciog place or to tbo seuido is very useful. 



DiPHTBERtA in All Bcuie RotitaKioiui (lutoosc wUif.h, on sccotmi of its nre- 
Talenoe, it« graritj-, its oonsequeaceH, and the frequency with which it m 
met with in Uui chiltl, taliiifi a promineut placo amongst the disonlers of 
early Ufv. TUq ditH-iuse uiduceH ^(roat Anwtiiia aacl prMtratiou, iukI is 
cJiariLcterized ountoiiiiL-iiUy by iullivmrufttiou of v»iiou8 mucous surikccii imd 
the fbmtatiou on Lbeiu of a more or Iet« tough anil iMtbttn* falKO mem- 
brane. The inSntDination ofteu spraude to some distacoe m>m itH point 
of ongiD, but nt first ia ustutUr confiuml to a crnnpamliTely limited area. 
Tbt Heat reri«a in difTeront ompb ; imd the srmptonis are therefore mibjeot' 
to great variety Af^oordiug to the part in which thg chief local oxproesion 
of uie diaeiUie oocum. 

Whf R tb« inflnRimAfory proccsH nttrickii tlie larynx the malady is called 
tnembmiiniis cmti]^, and tJtiR nns long IipUI to be n distinct afr«ction. 
Whotlur all cnsc-^ of mciubntnoiK! croup am diplitlieritio in their oaturo 
— wliL'tUcr a false mcmbrruio can bo devcloptd in the air-i»MWf;c8 apart 
fi-oni the diphtheritic poiiion — is a qutnUoii upon which patlKilogists ia this 
«ount]ry are still divideci That vienibranuuu croup ansra in many cases 
from tuts cause in undeniable. Instaucea have been met with in wliicli diph- 
theria has attackctl the pLiuynx in some lueiubers of a family and Lho 
lariiix in others. Thuui,I)r. Woodman foimd meuibrauous Imyugiliii in 
two intaote, aged reapeirtirely eighteen montlia and two months, while 
othem of the family suflerea from falae membrane in the month and 

Shaiyiix. Dr. Wilka has seen in ditTereiit inmateH of the nuiiiie house th« 
iitcaiu} romnin confinod to the throat, <tr Kprz-ad tlicnor to the larynx, or 
bu)^in in the lari-nx ; and Trousseau rtftr» to a caec rciwrted by Dr. A. 
Oui^ranl in which a httle girl fiied i>f Ijuyiigcal troup, and other menil>er8 
of the family snlfered immediat^ily nflcrwanla ^m pHeudo-membntDOua 
phor^'ugitis. Moreover, it is admitted by the bc&t authorities thst Uie 
mryugeAl fabie ineiuhruuc has exactly the laiue analuuiicril cbaractent, 
whether it be due lo the Hpread of » pharj'ngeal diphtheria or arise pri- 
m&rily ao a auie of mcmbranoiia croup. 

Advocates of the eiitHeutial ditTerence V)etween the two forms of illucas 
maintain that the cham-ltr of the two diseases is not the some. Croup, 
they say, is a sthouic disease, while diphtheria is asUienie. But some 
cases of croup are accompanied by severe ironstitultonal depreeedon and all 
the signs of profouml general diaeaite ; wbile diphtherin. ia not invariably 
accompanied by KynipioiiiK of proat^ration. In<leed, one of tlie pecidinri- 
tica of thi.q affection is the occurTonco sometimctD of marked paralysis rfter 
an attack nt soi*c throat so mild as to be aliinMt ovi-rlonketl. 

Secondly, it ifl pointed out timt in diplitheria the glands at the angle* 
of llie j»w are invambly enlarged, wliilu in membrouaua croup they are 
little if at all sQcvteU. But the larynx hau httle coimocUon with Uio sn> 


fWrficiAl cerwdl BlftiKU. As Dr. 51oro!l Mflck«iizi« Lok poinV.1 eat, in 

cancer of the lntT,-ux tlio ccrricul ■^hiiuls iiro iiot enlarged. wUilc if the 

nulJOTiaDl diabase slCvoL Uie plmiyiix^ Hk^sb ^buida are always ioToWed. 

llurdly, the couta^uusneffi of iliplitherut ih inaisted upon, while cO' 

lous croup is said not to be coituuuiucjiblu by one child to anoUier.,' 

it the rink of iufeutJOD is in direct proiiurtioD to the amount of enidv 
tioD, and tho reodinofis witli vliidi the niembrane cau be detiiohed and 
dispersed. la the ^ottis tho tnombnme is Tenr firm!; cxlberent ; in tb« 
phuTiu ita cunnectinna are much Inoscr, aiid it is luurh more eonly 
separable from the nmm>usi HiiWar«fl. Moreover, as Sir Williiiiu Jeuner baa 
ooeerrod, the <y)ti<litionR in wliioh tlie pntieDt is placed mr^- jiprcfitlr in the 
two caeoa. A child Vrith diphtheria iu its carlr xta^e is up and nlxmt, Idaaes 
his Inothers and HiKterii, and ban ereni- opportunity of cniivfTing the di»> 
case to them. A patient with menibnuious nviup in Icc-pt in bml apnrt from 
lb* other childrvu tuid carefully tended. Still, there hi vti'uuK widunco 
thai, in npitu of tbtsu tiindraiiccti to ita rciuly commuiiii'Ation. iiivmbiiLQous 
«loi]p mar be conveyed (rum one child to another. Dr. l'ren<l Blittes that be 
hi8 aeen the Iari'nt;eal disease in more than one <-hi!(l of n family at the 
eame time. Dr. Wilks U^lieves tbtit he has soc-u ilipLtJioi-ia be^iii in tbe 
liouae a» a case of 8U]>po»e<l merubnuioiiii croup, oud aft«rwnnlt( nttack 
othera of the inmates in the form of (lipbth«nfac phiurugititu Dr. A. 
Oiu'iard'B case, alreadr referretl 1o, ia nnotbcr instance of the coutogious- 
oesH nod interchaag^eanility of the two rarietiesL 

Fourtlily, albuminuria, vrhieb ia common in diphtheria, ia aaid to be 
laro in membiiuiona croup. Hut tins is not altogether the fact. More- 
oTVTi albumen dur« nut mn'ays appear in the urine at tbe b(^^uning of au 
attack of dipbtberiii. but may be dcLiyed for several daya. Now the dura- 
tion of fatal coaea of ci-oup ia often terribly abort ; 8o tliat the patient may 
die before the albuuiiuuria haa had time to occur. 

liwUj, pAml}-KiB in a not uucommou sequel of diphtheria, while ia 
abranons croup it is very rfirt>. But it must be remsmbered tlirtt true 
ibnnoos croup is an eiceasively fatal diwaae and eomparBtively few 
caaee remver. Even an a consequence of diphtheria the occnrreuce of par- 
tljsoi n rarinble in different epidemicfi ; and taking tbe milder caaea with 
lb* vntixer, tbe proportion luui been OKtimaterl by Di* Grecniiebl at no 
BMre ttnn one ia tnelvc. In conrakvccDta from mombi-anous croup thA 
proportion who arc likely to suffer from paralma would, therefore, under 
any circunuitances be very amal). 

* From consideration o^ the above facts and arf^mcnts the only conoln* 
moo to be drawn m that a lai-ge proportion of chhcm uf membranous croup 
«• cases of laryii;,'e&l diphtheria. It does not. however, follow that mem- 
Imuwras lart'n^itiM m nev^r due lo any oilier cauae than the diphtheritie 
poiaon. Tliecbild's larynx is eiipecially prone tjsnienilinuioiis infbuumation ; 

id if. u bae been positively stat^l, a true taU*-. uicmbnuie may be aafc 
by bunifl, acalds, aud other irritnntx lo t)io nir piiKsaf^ex, it isposuble 

Kt the d io ow o may occnsionallj ov^xu iudepeudoatly of the dtpbtberitic. 


Diphtheria ia met nith both aa nn epidemic and aa on endemic duMuet , 

and variea much in diarncter im<l aeverity at different timea aud ui differ- 

f nl lixnhlioH. It may attack children who arc apparently iu robust health, 

.loay arise in cachectic Kubjt>ctH. or appear oh u sequel of seTcrc (general dio- _ 

like typhoid fever tbe diaonler is apt to occur more tliau one.« isfl 

\>*f same iudiridual, for tbe protection it ofibrds a^nst a rccurrcnc4> ia^ 

by no means complete. Sometimes the sectwd iUoesa may be more eovore 


I»If)BA9G INT rin7.nRElT. 

thnn the first, ior a ohiKl who hiut pnascd eately throagh one nttAcfc taay 
Biiccuiiib t'l a Bccond. 

CattMtton. — Oil account of Uie suaceptibflity to diphtlieria in earlv life. 
cliil<lho(Ml iiiav Im.> vousiileretl to be one of the proi1ifl|>oetDg causeB of tlie 
malaJv. Infiuite uud^r twelve moutlis of ag« are uot often att««k«d ; but 
lifter t'lmt iv^e and np to tlie fiflb or aixtli year tii6 diaeaao ia freqitcntly 
met witb. After tbe sixtli yoar it tifpaa bMomes loM oommoc. and in <.-om- 
ponttively rare in the aAxiM. Besiiics this nnttim] nisoeptibili^, tJiere is 
pmbnbly in maiir r-nties a KpM-inl HutirpptibUilr inliorenb in the confltitiitioi) 
of tliB ]uitifni. SoiaetiinrH whole fanulieH are cut off during an eptdemio 
of Uic (H!rt«iiip«r. Sometime* sucMMUTe chUili<(>n of tlio iamo pAreotil fall 
TJclims to tbi; duscaeo at viiriouM tamc» luid in difltTeut pliK-i-n ; ftiid in ninny 
vnai-s tbia imfortunata predisposition ii]>pciirii to hv a bcrtilitnn* detect. 
Betitdea these general oaaiiea, eqiecial delicnoT of tbe tliroat mny render the 
cliild more aenative to the dipbtbcritic poison, inclining liiia to take tli« 
diseoHo irbere a stronger snbjuct woiiM est-»pe liltogether. Also the pres- 
ence of A cotarrlial voodiljou. of tlio fftDccx nt the tiuio of »pomu« to the 
uubpaJthy inJ]ui>aooiiiCTea8M tbe likvbboocl of iuf»ctiou. Tue scroftilous 
constifiitioQ tiaa been sud to induce a BusceptibUity to the diphtlicritiG 
vinifl ; and there ih no dmibt tltnt tlie mibjertH of thii diatheidH are, na a 
rule, ktM>iiIy Bensitivo to all formit of zymotic poisnn. 

Cokl and moiittitTc appoar to Iiato i«oine in6ncnOG in (piiekoniDg tbo ac- 
tinty uf the coutaj^uuH priucipki, for ilic diMiaiw iscouiuion in countiy dift- 
trict«. («i)ecially in damp pLncwt. iinJ in more prevalent dnring tbe winter 
months tlinD at nny otL(>r period of tbe year. 

W'itb regard to tbe exciting cauaes:' There cim be no queetiou as to Uie 
highly POUUDOU8 natare of the ^xiidntion from tbe nOecled surfaces, for 
th« disc'lini'eeB haTe often comaiuuicnt^d the disofwo by coming into eootaet 
with a hMluiy mucous membmne. Tbo virus may, boworer, bo also eon- 
Tcycd br more euMle emonationn irom the afiected person ; and it ia be- 
lieved that the contaji^ious principlo mar lie carried to a distance in the 
ekilbKR of tlie patient liiitifti'lf aftrr «mval««'<'iioe. or in tho dress o( a 
ntirsu tvbo huK not- liurKclf nutTLTCil frr>in thu dii!Or<Lcr. Indi-bd, nil tbo sar- 
rouudiiif^s of the ]iutit.'ut a]})^;!^ for hoiuo time to be cupublf of t^mmuni- 
cntiug the diseuse. It is even stated that in certain cases a coniiUeHeent 
may be still tbe chaonel tbmugh which the diphtheritic virus is conveyed to 
exceptionally susceptible KubjcctH, although n period of nmatbaluiftpJitpaed 
aince t'ecovi-ty from Ibti ditiunler ; but iu 8ucb n ctme it would be difficult to 
cxcUido other uid more recent Bources of iufeetian. 

The poison may be drawn into the lungs nitli tlie air or swallowed in 
contamiuat«d water; but miirh unoertainty exiHta with regard to the lavs 
■which t^ov<ini the tmnsmiflsion of tJie infective matter. Old ceespools and. 
draius apticar to prcHervo the conta^om for along time in a state of octLT* 
virulence, but tliei-e is no proof tliat the poison can be generated Hpontane- 
ously from onlinnry filUi. The disteiiippr may originate in a district 
un<ler one Mt of eoaditionti and l>e diatrihiited under other and different 
coiiJitioiiM, There is no doubt that iiiiwvuitfiiy uurrouudiuf^ lend to favour 
the Kijreuil of the tliseose : still it is prububle that other Influeucea also 
regulate the difFusiou of the iufertion ; for when an outbreak oeenrs id any 
distiict, it is not always in tbe poorest aud least de&aly localities — in parts, 
that ia, where the disease would lie exi^ected to be most active — that Uie 
lai^^t iiiuuber of cases occurs. 

Id many outbreaks certain faulty condttioos, such as pollnted woter- 
supply, long standing accumulation of excremeutitioua mattei's, andimper- 



fiel JiewerHge odiI drftioag« geuenUly, ar« found to !>« common to all 
dvellinf^ in which tlie ai»Riuie Hl>i)«ai-». Thc»4a saTiitnrv (lefioieDdes 
Umi held to fumisli an explnnntion of tht; Kournn of tlio infection. lu other 
maw no biicIi c^omiuas couihtions can he dlsoororcd, and thci origin of tbe^ 
outbreak ia ksa mhj to ■ooouiit for. ThU ttiih the aute in no epidemic oCM 
diphtheria which occuired at King'ii Ljrmi. and vas reported od by Dr.* 
Auy. Hero personal conTeyance of the difteaiui vas pntdtively oxdtided in 
Ute majority of coaes. The milk vtm not at fault. Tlie walor-Huppl)-, the 
^fstcoi of druinngc, and th<! mvtbod of dinpoiuil of the excrement were in- 
■officieat, either singly or together, tu csplaiti the distiibution of thn infoo- 
tion. It was, however, noticed tluit bxcnrations bad been in pro<n:vM ta 
tlie mud of thetuicieut rircr-bcdimdof a creuk which hiKluucL' becuascwf^r 
in connection with the tunn. Dr. Airy KugfjuKtji that by thit> meanH " long* 
bari»d germa of some iadigenoua dtpbthehn, cnumng micromTnes," may 
have been diaengnged ; and thai tbeae carried amoii^^t tli6 mtLubitanta, 
and sided hy Maaoo and atmosphere, may have giveu rise to the out* 

DiphtheriA is no doubt the consequence of a specific poison, howevi 
this may orii;nnate. The esnenco of the di»e4u«e hoii been attributed 
uphenoal bant<*riA (miorooooci), whicli have been discoverad Bwannin^ in the 
f&hte membranes and exudations from the tnflnmed mucous earfai>efl ; hut 
■a ttimilar Imctcria bare been found in tho secretinnB thrown out by ordi- 
nary' Don-ffpet-'ific storontitiK. loo much impnitanon must not bo nitrilnit^d 
to the prt^seiKs? of tJiew oi^aniRma. Thft Jtml nutiirc of tbo Tinw biw yc 
to be di»coveri;d. Thc-(H»uuiL- with whioh diphtbtiria hfui tlm closest lUnn- 
Ky appt-nni to be itcadatiitu. E^jidctuics of the two disordera aru frcriiuentl 
aeen to pri^vail m ths same neighbourhood iLt tlie same time, nnd it waa OQ' 
rappoaeU that the exoitiuf cause* of the two diaenaes were tbe same. It 'a 
now. bowever, acknowledged that they have no uutiiidly protective power ; 
and there ia no evidence tbut the oontagioD of diphtheria luw over given 
rise to scarlatina 

Mortfui Anatomt/. — When the phoiyas ia examineil the changes foaocl 
OD tiie inflamed mucoiu* membiaiie are as foUnwH: the Hurfiice becomes 
byporsmic anil swollen, nnd after a few hours is covor^'l with a whitish oi 
yulorwiab layer which adheres cloaely to the mucous mcmbmno beneath It, 
Btting Bccunitely into erory dcpresHion of the surface. The layer when 
first formed cannot be removed ; but as it increaseii in extent and thick* 
neaa, it gradually heoomofl tougher, and cAn then bo peolod off the fiurfnro 
to which it atlhi-rex. Iditor, it bft^s to luottvu mud may ecparutc spuu- 
laneotuly. When uncovered tlie mu(?oit.s tnuuibniuc! iiiuy bi< foimd to be 
reddened and thickened, and if the intlauunatiun has been severe, raw-lo(rfi- 
ing or «veu ulcerated. 

On examiuatiou of the false membrane, it is found to present to tho 
naked eye the appi'iintinf of cim-^iibkt«il flbrino ; hat under the miero«co^ 
iB seen to consist of prohfcmtcd epithelial ocUa which are fneed together into 
a network. Thpse c^'lla ai"n cloudy from a peculiar degeneration of their 
protopbwm. A vertical wction of the layer iiho^vfi the undermost cellx 
to be much tmuiUer than tlioae nt tlic Kurface. and in a far lem advanced 
atage of degeneration. Bliniite cxtravoaationii of bloml oro olau scattored 
through tbe sulxtance of Uie Iiiyer. If thoTertic^il section be mode meiii* 
and be carried down through the rauconu niemhrane, it will be seen thnt 
the exuded hirer in ebiitod directly u|>oq tbe b;iiteiut.-ut mcmbraue, tokiiijf 
tW place of the ordiiiiuy cjiitbeliiil coating. Wbt-n the morbid proce: 
I to on end, degeutratiou ceases ; u little purulent matter, formed b: 




uoRlbered new cella mixed ^tli ecnim, appears betireen the mucous sorfice 
And Lbe tnlsa membraue coverinp it, nnd the Utl«r is detacliPil, 

III tite lari/nx tlio niucouK tiipnibmno in intbunod and kwoIIoh, mid » 
fibriDous esudntioQ is thrown out 1}«tw«fli) tl]« bAWiucm m«iiil>mno wl tbo 
«pitlielial covering. Thin an csiuuinatiun can be aepusted into Inj'cra coo- 
iJUitiDg, nrcording to Riodtleificb, of alteinutiiig stmEa of cnrimsculAr e)^ 
Qonts (1«ucoo}rt««) ADd of liltrine. The superfioiil epithelial \a.y^T Toy 
|uickljr diiuppears. The luiorooocd, wludi lurc found iu iiointiu^ iiumbeni 
, the (alBe nietnbniue, hnw hct-n nlroady reforrwl to. Acconliii^c to St-nntor, 
ihene organisnis nre common to all fonns oi Htcnnatiti^ and ure piobably 
ideaiicaf with the »])Orefl of the leptothiix buocalia. 

Tho cousLstt^iicr df Lite hlM metubrnne varies in different caMS. It ia 
often lough mid toune-iouii, «q)eciaU;)' iu Iho lur-pnaangcK ; but sometiniotiui 
Terr soft aud pultoeeous. The Intter condilioo iu <.'ommou n-hou tlie falM 
memliraiie ol-cux>)C8 tho phornix in nuie*) aocx>mpnniecl l>y aevere coiiHtitU' 
ioual ttyiuptouiH and grwat bodily prostnition. Tli<> more uaual senls of 
lie fal»e mtmbrAue im tha toiiMls, tn-iiln, «oft pnlato and bncb of the 
ptmrrox ; the uasal paasafjes ; the huynx atd trachen. Lotu commonly it 
found on tlie coiijuniHiva ; at thn ))ordern of the aniu). nnd in girls of the 

inn. 8oiiiotin)c« it nppMtra on uounds of tlie skin. Tlio mucomi meio- 

%<t is u«UAUy, AS has be«n «»id, oongost<Kl nnd awollen. It is very irritable' 
nod bleeds eaoly. SometimeB thoro is sapetficial uhroration, nod in rare 
'CueH the ulceration extendii deeply. luid Hlou^hiut;! of the tismieii may ocxntr. 
8midl ulffenifioiit* H>i()ut the edges of the gluttis are especially commoD tn 
tCases wb&re tJie iiitlutiiiuiitioii oocwpies the Iar>-ux. Tlie iKrviual gUoda are 

iMva from ntpid pn)Iifi;nition of small rouiiil oclU, nnd Uie surrounding 
[tissiiea are inlillmted with Hi^rum cnutaiitinir Rcntterod piiK-colla. 

Jlesides tbe^e local pa,thologicnl changes, other organs of the body are 
ofti-n Bffe*Tt«d, Tiius:— 

The lun'j* may be the Heat of lobular pneumonia or RoUaptie ; and Uia 
ftir-pnssngcs arc sonicitimoit lined witJi faJmi membrane aa far as their Hmaller 

The krjart, ulthouRh Ihself showing no signs of diflc-nse. may hare its 
Tight Tentricle filled with q polourlesa aule-mortem dot whiub exteoda into 
the ventricle, ft ia sometimes slated that the lining membrane mav be th« 
neat of cudocitrtlilis ; but Parmt nsaertH that lie haa never met vito endo* 
CAnlitiN in a case of fatal diphtheria. He believes that the beading elae- 
where deHcrihed, which is almost a uatimd <.'Oudi(ion in many young 
in&uita, haa bi-cu rai^tolien for the retiiilt of inDanii nation. Pcricarditoa, 
however, \» ot-rahinnnlly present ; and IQ a few inataDcea a granular degeu- 
eralion of (bo hnnrt-wAlU baa bMm obwrved. This doganenLtiou is oon- 
Bidcrcd by Lcydfii, of Ikrlin, lobe of an infiHminntor\- chontcter. Itconaista 

a multiphcjilioii of the intermuscular nuclei which atropiiy and form 
RpotH of degenenitioii. At tlie sunie time tlie raiiHiiulitr libroa nud«f|{o tatty 
degeneration. As a conae<}uenee of tliesc changes tito henrt-walls bocoma 
Hoflcr iu vouaistencei estxavamUoua of Ui>od lokii place into them ; and 
their cjiviHea are dilated. 

TiiB hutney^ may bo i>nlftrged and pale, with more or leas granular 
deposit in the renal cells. The cells themselves are often detached ao oa 
io block up the tubes. Tlipy are mixed with hyaline costs. 

Besides the above changes, thei-a may be extravasation of blood into 
the various organs and beut-^th the mucous and seroua surtooes. Thia 
oc<-ars in the malignant form of otlier varietiea of acute ^niioeiOo diaeoBB. 

Ou ai^ooont of the 6^uent occun-ence of paralysis during connU«c«uoa 


from dipbthem, Uie nerTottit PTsteni Ims been carefully esamined for tagnu of 
degvncTKtini). Cliamnt nnA Viilpian were the first to discover indicntinns 
ot patholotjical ch»n«f. In tlit year 1868 IliCM observers dc-tectc^l gnurulur 
degenentioD of ncrvoB and muiurlcs of Ihc soft puliita In tlit; motor Deireft 
of tliis port the tubules were euipticil of tlieir meduUiirv ttubstanoe, sdiI 
their Deurilotnmn cotitaiiied many granular cells. Oertul, in 1871, fouiHl 
miuiy L-stmv.*uHtti'>u8 in tli« Bubstiuice of the bntiu. ^pitinl onrd, and spintil 
nerres in a ctise wbore i]«atli bnd occurrerl from diphtheritic pHniljwjs vrilb 
ceuftnU atrophy of inusdti. Similar estrftraeations bavo been found lij 
Buhl. In atiitition. tliiti obserrer noticed tht> nervea to be thickenal ak 
their roots, and tbeir ttbenths to be lilltHl with li^^-pertropliipHl hinphoid 
oellK and nuclei. Dojorine, in Hvo caaea of death in ohi]dr»n fp.)m diph- 
theritic paralysis, found iu each inatonce ehaQ(:(ea strictly limitc^l to tb« 
nerveif aupjilyiug the paralysed parts. These clintiKos r-^risistetl in ii defen- 
eration of (lie anterior roots similar (o that which takes place in the distal 
end of A Dorvo aft«r seetion. He attributes the degeneration to changea 
in tliB pray matter of the anterior ooruiuu 

There is no doubt thiit diphtboria is a specific contimious diueiLse. and 
that it is, at Iciut tinnlly, a coiistitutianol one ; but uninions differ as to 
wbflther tJto mfUady ia constitutional from the firM. The more conunonlj 
received opinion in, pcrhi^s. that the affection is always a constitutional 
one, and tint the tliniat lesion is its chief locid expression, analogous to 
the rash of Bpccific fevers Some pathologists aw, however, inclined to 
believe that the lesion of the mucous membrane is nt ilret a purely loL-al 
atlmsot resulting directly from contact with the poison, just as the pustule 
of amAU-^pox nmy bo excited locally bv tlii> proeestt of iiiooidntion. Accord- 
ing to Uus view Uie constitutioaal sunbring would bo of Uio nature of sep- 
tiaemia, tJie bloud bein;; directly contaminated by absorption of a specino 
virus from tlie diseaaed spot. The well-known influencn of a oatarrhal 
state of the fauo^^a in inoreasinff the mist^eptlbility of tlie indiTidual to the 
diptberitic oont^ion (teems to lend »iipjK>rt to this theuini'. 

S^mjitontK. — Aft iu nil forms of zymotic diHerufe, the uiiaet of the iUnem 
ia preceded by a pi^riod of incubation. Tliihi period may occupy only a 
few hours or may hat for a week or eight days before the syuiptoms of tn- 
nsioD are noticed. 

CsMM of diphtlteria may be dtvidetl, accordinf^ to tbo gravity of the 
symptoms, into the mild, the severe, an<l the malignant forms. 

In the mill! form of the difloase the child Ih a little fpverish, often com- 
plains of hftsdache, and is unwilling to swallnw solid fooiL The ferer ia 
■Ught, the tempornture often rising to twtween 101 and lO-^", seldom 
bigiier. (Thus, iu the ciutc of n htUu girl, aged two yciint nud ten months, 
temperature: second day, morning, 99.4'"': Kveiiinu. 101.6. Thin! day, 
monung, 99.1 ' ; evening, 101", After this date the temperntiirewiiH normal 
both moruing and evemng.) In all cases there is some languor and loss 
of spirits with a certain expression of dis1rr«tB in Ihe faf«. Evtm in slight 
onw a Uttlu ohange ia notioei^l iu the (pinlity of the voioe, which beooiuea 
nasal or throaty, ^^omiting is not common in the mild form, although in 
the aererer cases it may be a ti^uent and ^Ustressing s't-mptoui. Some- 
times the symptoms are eren less marlred. The child may taVe lits food 
as usual without any complaint, niid only show his indi>:po8ition by a ei>r. 
tlia pallor of face ajid want of sprightlincss iu bia loolc. 

Whcti the throai ia examined, the fnuci-s are found to bo ml aa/^ 
nrolten, but mora oa one side than on the other ; the uvula in distincT 
inorMMd in mm ; md on one or both tonails a gray or fawn-coloit 



tou/fh-lookin;; opaqnc patch will W flocn, uminllT <»Mtipjiiig tbo anterior 
face. Tbu jxttc-h muy bo a cuiiliiiuouR I&jcr of »om« ooiUUtilotioe, or maj 
Iw compOflecl otmoixot taine mumbnuie BciiU*re*l over the surhce. T" 
tiowever, sood umte bo aa to form h more cobereut coating. In all 
the ({UiiUti at the (uigles of tbe jaw are teod«r and «ularg«d ; but tlua 
s^iiipUim is often not marked until the end of tha eecond or the beginning, 
of tuo Uiird d&y. f 

hi the mild form Uio tompcmture often fells after thiM or (our daja. 
Tbe gciiftrnl R\-mptoma contiiinc trifling ; the child takes food nitli ai^)e- 
tile : aii<l unless lie attempt to svalluvr noltd food, deglutition ia occoio- 
}ia.iiipd by little distrf-Ha 'File false membrane may Bprewl n little along! 
the soft p«latc, but usually xenuuiu Uuutod iu extent. Vcjy quickly it bc- 
(duH to scjnnite at tbe ragae taad tbeu beoomfs dbijicbfd. hx rtim caws, 
after spoutattvonH wpiLr^tion of the first pntcb of membrane a i«BCond ap- 
p«*r8 upon tbe mucooa Bm-fHc<'. 1 have cnown ttua to happen in one in- 
sfaiDoe. Tlie 8oro throat may be accompanied by aoiae disclinrf^e from tbo 
vow. Usually, at tbe end nt a week or ten days the cbiM i» oouvalemeat 
from tbo throat nDoction ; but it still romoins lo be soon whether ho will 
escape after iU-contwquoucot). 

k £i tlifl a^ixre form tbe diaeoRO may be serere from its intensity or dan- 
■geroaa from its neat TbuH, it may spread widely over the phnnnix and ba 
Aoeonipanied by nRns of norious nonfltitutional ftufforing ; or may attMl^ 
the lazjnx and, alUioui^b limitod iu esteut. produce tbo graruit conso- 
(jueo<^eH from interference with the reBpinitorj- process (membranous 

Stivers p/iarj/ngf^ diphtheria mav begin witb the mild genei-al symp- 
tomu which am onnmou in the aligbler form which htut been d(«cribed ; 
ur limy be accoinpani«d by maoh more serious pbonoioena. Thu^ the 
child c'omiJains of difficulty of swnllowin;; and of racking headache ; lib 
face M iiale and dintresHed ; fever is high ; Tomiting may occur on any u^ 
t<:TtipI to tiUte food : and the patient may rvpii be conrulsecl. Tbe fol 
mcmbrnne in the tJiront i.t tliiclc and p^iK-nilly coherent It iqiroadg mpidljr* 
OTcr the tonsibi, the iioft pulit^.', imd the Imck of the pbsnmx ; often prne- 
tiBtes Into tbe mwial fomne, or fonux pntcheu on the cheeka. tbe gums, and 
tbe HpR. Tbe odor of (he braatli is soon noticed to be fetid or even gao-l 
eaous ; and a tliio offeuaive discharge escapes from the noatrila and ' 
Toa orusta at tbe openings of the nares. 

The submaxillary glnnds are ouhu^d and tendor : and there is mui^ i 
swelling of the Deck. Souietime» bsemorrbAgea occur from Ibe nos^,] 
throat* and guma Tbe face ia pate witb a tendency to hvidity ; the pulso 
is rajMd nntf feeble ; appetite is completely lost ; the boweU are generally 
relaxed with thin offonrnvn stools; and there is great prostration. Soma-, 
limes in these coses tbo folao mombranc is loose in coitustence and maj^ 
even be pulta<-POiia. It may oHKume n dirty gray or brownish hue, and ig 
sometimpsalmoHt black from admixture with blood. 

When thfl f>nd is favourable tbia form lasts for ten days or a fortnighfci 
After a time, if no aerious ooinplicntion occuth, tli« faltw membrano scpa^ 
rates and ia not renewed; tlie swelling subsides; the poise becomi^a 
Btronger ; the appetite begiua to return ; and tbe child entere into cou- 
voleecence, althuugb tor some time be remains amemic and feeble. Often, 
liowerer, the patient dies at tlie end of tlie week either fn>ia exliAuxtion. 
from estenuion of ibe infl.imniation to the larynx, or from one of tlie com* 
plications to be afterwards dowribc<L The mind is nsoally dear througbr j 
out, although in tbe worst cosea — tboso in wbicb the disease approHoEfl~ 

•irrnERiA— PTUPTOMft. 


most Dearly to tLe tna]ign»Dt t>-pe~4eAtli m»y b« precnlvd hy delirious 
vnuideriii-^ or triiii)oi-. Iii such cases a real aeptiewmia may occur, the 
blockl being poisoned br the iibsorptioD of foal putrescent mattera in con- 
tact with the tisHuee of the ph&r>-nx. The otuld often sluvers. fuid his 
temperature rifies to lOS'^or 104^, oft«n RinkiDg agaiu iu rapid dsUlv vmiaf 
tiona. Tlio pulse in Rmall aiid fooblc ; the oyen euukcn and dull-looking; 
the compk-xtou of a dirty vcUuw tioL, Tliere u> often ejHfrfaxiH ; the cer- 
vical glirnda KWL'11 to n large )u7p ; uid tite lfK»«e areohu* tixsue of the nv^ 
is infiitrnu-il uith scrum. Tbo pragtmtion is nxt.rcn)€ ; npotJij ia comj^ete ; 
ddiritim oomc« on ; and the child quickir dita. 

In iteTcrc diphtlieria the uiuouni of fever ranca Even in -very bad 
oases it need not be hi£:h. Sometimes the tempemture ia 103 " or ICU° at 
tho beginning of the iUnea^ and sinks to the normal \o.vf\ or cvoD bolow 
it when the more aorious K%'mptums ducluru Lhi-mseJmi. Homelimus idter 
diUinj; it niaT ^&in hecomu el«irnted and rtuith 106=' or higher before 
death. Some inHummatory pumplimtion ia then probably present. 

AlbuQiinuria iu a freijuent 8>Taptoiu. It oucurb ia about two-Uiirds of 
tlie cases, but does not ceceitearitjr impl^ gravttjr in the prognosis. Its 
amoiuit is usiioll; in proportion to the exLont of surface involved. Tb 
slbumiauria anpeam to be the consequence of a rapid eliminAtion through 
the kidneTs of iioiAOii nbfiorlted From the affected tnuniua membnuie. In 
severe caaes it mar l>e found ns early as tvrenly-lioura from the beginning 
of the iUnem. liiis \», howoror, exeepti^Hud. Usually it apponrs on tbo 
third or fourth day. but it may be irametimea delayed aa Into us tho ninth 
or tenth. Sometimes the urine is smoky. It containn an excess of urea. 
and hyaline and granular rastit niny ba detected in the d(')Kisit The kid- 
neys are in a state of mild pnreti<:hvm;4t9us m.'ijlirUi». but this pmSKt off M 
oouTalescenoc bcoomos csUblL-ibct.'iuid mri-ly IcavcM ill con itequouow be- 
hind. It is Tear rare for unemi.? k^ mptoms or dropsy u» occur. 

When the disease attacks the larynx (lan-ngeal dipnlheiia ; niembnuioas 
croup) tlie child is at once iu setious daugcr. In the nn^niity of cases the 
laryngeal disease is duo to exti^uaiun of iufhimiuatioa from the fauces. 
Less iNmimonly the inHammation begiuu in the trachea and sproads thence 
itpwanis anil downmuds. Coses wfaei-e the dlMSse derclops originally in 
tm! glottis (the so-^aUod true uicinbninuus croup) are very rara. Still 
rarar are the cases whero lite faiao mombrone remaiuH Umiteil to the glot- 
tis. In my own (ixpi^ricuco I cannot call to mind a single caae of mem- 
branous kryn(,'iti» m which some evidence of false membrane in other 
parts was not to be obtained. In most coses there wns also exudation io 
the faucee. In a few the membrane bad spread down the trocltea and the 
fauo«« were fre« ; but even lu those cases patcfaes of exudation were usu- 
ally found on exauiiuation after death nt tlte liack of the nnreH. 

The extension to the air-passagea often takes jilaiw quito suddenly and 
mieip<y^r;t]lv. The ]>r6cedijig symptoind hml bccu sliKi^t. attractiag litUw 
utU-ntion, wlicn auddeulr the brcidliint:; is noticed to bo striduluuit. Thu 
symptoms of membranous erotip then develops themselves with starlliug 
juUty. Usually Die sore throat and signs of catarrh continue for sev- 
' days before any more alarming symptoms are observed. The child is 
iKn thought to be ilL He seldom refuses his food ; aud although a 
little languid and unusually anxious fur diiuk, dueu not appear to be dis- 

Wbea the laryngeal disnase beginsthe l>iiMLth-M)undN lose their ordiuary 
diancier and Income harsh and stridulous* At tlie sam^ time the cough ia 
bard aud bartih and the voice and ciy urc hoat^c The dmngo iu the ebif 



&ct«r of Uie breftUlijig loa; be Lhe earliest of Uie new sjmptonui, or twiy 
he preceded bv the chiuige tn tlie voice and cough. 

Thiit fAtige of tho difiease nuty contmue for ttevenJ days ; but oft«n nftcr 
a few lioure tbc breatfain;; bocomee greatly oppressed, and attacks of Tjoleut 
djvpavBa throw tbo patient into the grf^tenl <lietre»i. In th^ne attncks 
luiw«Ter Tioleot they may be, there in no ortbopocra, for tlie breathuig in 
not mora oppmuutd whro tho hcnd is low. As n rale, tiw eliild hes bat;k 
in hid cot or in hin mother'^ anna Hiii boo is lirid ; hit) mouth is np^'ii ; 
Ills eyes stare mildly, and he looka dreadfully anxioiu and fri^ttened. Tlte 
dyB])n(Ba afieotii lx>th respiratory tnavementa Each in^iratioo in pro- 
longed, high-pitched, aad in«talhv \ tho oxpiratiotis aboHer and hanh : the 
couf^h hourse luid whufpcring. If tbu <-Jif»t is uiicOTcrvd nt this time it 
will be iiotioetl that at each inspirntion the lower hiUf uf tlie breast-bone 
bends inwards bo as to leave a deep pit in the epigaatnum. At tbs nme 
time the iDfercoetol spnocs de«pea and tho supra-atenial nolcli is depceeBedi 
Th6 attack of d\-?tpuita huttit fTx>m a few miuiites to a quarter of an hour or 
loti^jor. ^Tien'it aubiddeaUio child 'a terror diaappeara; hi« Iwoathinp be- 
comea loss noi^ and atridulous ; hia respiratory tfaovementa 1«88 labonous, 
and lie pnsaea into a state of coaipamtivG ease. Still, the breathing is 
rapid and aadible; the oArvfl work rioleut]j ; eonio lividity nmaina in tiie 
face, and thoro ia conaiderablo re««eeion of tb« soft porta of tbe chost in 
iotipiratioa. On examination of tlie rheat^ the bmatlt-sounda ore accom- 
panied by ft atiiilor 4>oRdiict«d from the Inrjux, and this may completely 
oonoeal nil naliiml vrrgic-ular miinnnr. 

The utlncka of dyspno-a return at abort intorvala, and arc caaily oxcdtod 
by movement or by an\-tliing wliicU iiritatfa or nutates the patient. The 
cou^ oocuTR fro<}ur'iitiy and is hooi-Re and wbbtpering. Sometimeo tbo 
patieat «xp«cU>ratt.'s patch«a or Mhrcdn of foliK' membrane ; but unleat tho 
trachea bo opened Uil- chUd torely expcln enough of Ihc obettrudin}; mib- 
atance to produce appreciable relief to hia aymptoma At each recurrenoe 
of the dy^noea the attaok ia more aerere than before, eo that cradaally the 
child [waaea into a aemi-aaphyxiatcd atutc. He lica bw^k wiUi purple hpa 
and livid face ; hia pulu* ia feeble, frequent, and very irrejpilar ; hia breath- 
ing rapid and shallow, although bia oorea still work ; bis forehen<l clnmm^, 
and hia extremities cohL He ofleu morce luB nrma reetlesaly, and lua 
heart's action may become very intermittent, n curioua pause taking place 
between every two or three pulaatiouH. On examination of the cheat there 
ia UBtually good r^eonance, except perhaps at the extreme boso. The breath- 
eoumla are obHnured by conductefl atxiuor and may be aocomponied by diy 
rllonohuK If no opprative pi-oeedure 1m> atteicipt«<l tho drowwiiesi deepena 
into stupor, and tho ohUd sinks quietly or dies in a la^it etruggte for 
breat h. 

If at this atage the trachea be opened, the immediate eSbct of the 

r ration is moat striking. In a tavoumble case, where the trachea below 
opening is not obstructed, the child i» at once rclievet,! from almost all 
his diairviui. Air a^^aiu peuetrates deeply >t>to the luug» ; the lividity di&- 
Ai^MArs ; the niatleasuoiM subsidea ; the breathing becomes natural ; the 
nariM coam to act, and the look of terror and sullering paseea off and may 
oven be succeeded by a smile. 

Wlien the disMtw tlius attacks the laiynx tbe duration ia usaullv very 
aliort. From the time when the first mgaa of stridulous breatlting are 
noticed to the end only a few boiuis may elapse. In other casca the child 
mi^ live two or Uiree dxya ; bat thia longpr duration is doe to alower 
pfDgreaa in the eai'lier part of tho illnORH. When-serious dyapntaa super- 



i08 Uid child, if not rclictwl hy n|)erntioii, Beldom MirriTtw Uxf next 
twenty-four buiini. Sonii'tiiiicB. Iiowertr, if Ijib ta\au tnotnbranu in rcry 
liniitetl ill extent, reajvery may taku jiliice. lu tbt-w owm the Hym^itoms 
•TO wlclom vfTV emrerc, and in pm-lu-iilar the attaaks of dyapncea, if pr 
ant at aH, aro uiild luid iufreiiuent. Tlie fnTouiublo dianue iit luurkvd by < 
len Imboured cli&ra«ti<r of brHutliing, ii l>ri<;lit«r look id tli« fnce, iiicr 
loooeneas and more natural <|iinlity of the cough, ami a n>ttiru of i 
juiUity to titL' niniiiier. Still, tlier« is little doubt that ranoy cas*es of 
ti]ipo!wd rt-cov«i-y froiii uuuulimuoutt eruup are really cnst-M uf atridolous 
lar^'u^iliH, wliicli is a mucli ii^dci* Ptimphunt and rartlv ctidi) fatally. 

In tlie tnaliynani form of (be disease the constitutional ov-niptoms are 
rery aeverc, and ciny be quite out of proportion to tlio ninoiuit of local 
lerioQ. Vomiting is ukwiIIy fTOqueiit. Tbc-r* itt often diiLn-1ia-.i. The 
H w ]vUe atid hng^^'ard-lookinf;, and s^oms stupid and ilmvfuy. Hifi skin 
" mih ^letecbiif!. His puW is rapid, simll. aud feeble HiH fvut 
bauda are rool and danitiiy, and 44ven the intei-nal tetiijwratun; of tho 
dy flr^dom roaehoH a high clovatioii. Soniotimca, indff<i, it \» iioncal or 
•IMS iflibaormaL Tbiu o^littto boy, aj?od two years and a ludf. wns ad- 
mitted into tlie "Eiwt Ijondoii Children's Hnspital with wfiNh-Uiiiin-r-liko 
exnilation on thi> fauces, pvat Kwpllinf ; of Llio ('»rrvicid ^landH, ouil luiU'ltwl 

fiPcwtratiniL In tJiis hoy tlie t^mprrntiirn never rose nbtivo 08.2 , nud a few 
loure liclnrtT death was on!_\ StT" in the rectum. Ilio child died two daj-a 
aftdr Aihiiittwou in a nHMuUive rlt. 

Til© fttbwf niombrntK' is j^t-ui-nilly of a dirty-brown i,-oloni*. FAtonsiou of 
the iaflamruAtion t«k«« placo rapidly inUi Iho no<:«e ; epi>4tiLxi« often ot^curs, 
or ihmn is a flow of thin blood-ataitied tliiid from the nosLrilH. Sometimes, 
the lachrynial ducta become nliHtniRt«d ; lh» eyes then look wnter\-, ani 
talaa tnembrano may ofen appear on Iho conjun<'tiTic. Th« mitrous m*m-" 
braoo of the fnucos may b»comu ulcenitod or gunt^nuiiH, and the Kmell 
from the moutli is very oflTenaive. HaimoiThngeK may oceur from the giimsj 
ujid throat The tirioe is often amoky and nlmoNt aln-nytt idbuminouR.] 
Pelintua oomefi on followed by tttupur, aud tho uliild <li^6 exhaiutcHt 

Secondary Dtfthlkeria. — 8ouiclim(*4 diphthcnn occurs itecundarily to some 

acot0 diaeaite. Thus it may arise as a complieaUon of typhoid (ever, 

>y»emia, eiyaipelaa, measles, aoarlatiua, w-hoopiHj'-coMgh, or other form of 

iit« iUneaa, In th«ac caaea tliu niuouut. of false membrane in usually 

itanl iu extent, but tlio iuflammalory pniceKs '» niit to run ou into ul- 

'ntion or oven f^iu-n'<^tit^. The uleent are rounded or siouout;, aud may 

.etmte dee(J\' iiitu the tiiwuetL Ciangr«nc in not common. It uHunlly 

cuTH iu die tonaihi and pillnra of tlie fauces. These partn bernnie gray 

d Rxludn a most ofl'omavr> odour. Ttio hIou^Iis uopamto after a time nud 

ove gTAyiflli, unlimlthy-looldn};: yiUt which iu favourable c«B«s may L«al, 

"th (TonxidumblD cnntnictioii of luniie in tlie afTentod parta 

CompiiralinttK — Tb« ordinai'v courso of iliphtlinm may ho interfereil 
Ui by variouH con)plic.atiou9 which delay r^oov^ry or unfavourahly in- 
'nc« the ix^fuc of tho illiictM. The aeeuiT(?nt;u u{ albumiuuriu L-anoot 
looked upon as a eompHratioii. TIiIk ayiuptom is found in mild as 
aa in severe eaacfi, aixl it far more oft^n pnwait than absent. It ap- 
pears to be the coiit<vi{Men<x* of eliminstioa of the poi»on by thu kidueju, 
and has probably httlc inSueneo on the protniosis. Tho compheatiou* 
which will be considered consint of the fonnation of false membrane in 
aaaiMBl situations ; tho o«eurreuce of inlLuiiJualion of special organs, such 
as the luiitca, the beattt aud the perieaiiliinii : tht.' fumiatiou of a thrombi 
>r large rewels ; and the uppeanmce of paralysJA 


Xiuftl (1ipl)1h«ria has b««D slrendT lefeirec] Ut -m coustitutm)/ u i;\-iui>- 
tom of the runUgn&nt tj-pe of tlie di«efise. A tliphtheritic potyza ifi,"liow- 
6\eT, sometiniefi seen as a complication nf milder attaclfa. Iii tix^m- cttsta 
a thin diHcliarge flowi) from uie no«tri], nsiially at finit OQ one udo otily. 
It pnMlti<»!» ftoitic f'\«'orii)ljoR of the ninrgin of Uit> nnsal oiM'iiiu^ as well as 
ei the upper lip, for theaa parte ftro oft«o red and raw-locwiug. No douitt 
t}i« presenne of false iiicmbnuic in tliL- tiAsal paiiaage« ifi a mga of tJie ut 
RioRt j;mvit^ ; hiiL I liave known eoryra witli excoriation nf ibn DOtAxU to 
occur m ci\»fst of a oonipAr*tiTf!y mild nntui* witJjout producing an uufft' 
TuumMfl influGUCE! upou tho coiithc uf tin- illnL-ss. 

Sontetimeti in e[>idemics of dipbtherin mare imusiud tnaiiifeHtatioiiB of 
Mm liisfonse am met nith. The false iii<>nihnuit> ma; form uyaa the coa- 
juudinu, till* L-xt4-^ni(U auditor)' iu(.-ntu», thu outluta of Uio riii^iuii nud ru:- 
lum. upon tbif glaim penin. and upou any woundu or abndded stirfaoes 
present on tiie sldii. Often after trscbeotomy the edifee of the vronnd 
<luickl,T keoome covered by tbo diphtheritic exudatioo. These exc^tioaat 
atata of the false luenibroue may be the only local uigna of tiie ais4->UQ 
to tio didcorvrBd, or may be ocuouipauied by the uhu&I nflTectioii of 
the throat. Wbeo a wound or obraided surfaoe becomefl attacked by the 
diphthfritir. procees, its tK)r<Iers become purjile red and sirollen, ana tlie 
Hut'fnce pount out a pivifiwe, waterv, fetid disduurge. Soon a pellicle 
tonna on the sore, aiid from tliis potiit the diwtose may xprcad ovm* the 
tikin. Thus the dim'burKe irrititbcs the ueighWurint; cutouooun eiirflBoe ; 
little TtsirJes form, lirtuk, and Iiecome llicmKelvpH courerted into diphtlie' 
ritic snrca povereii I>y the eh.inii'feri'itic fnlse membnuip. In Uiij* way, ao- 
conlingto Tmusseau, thf^ diphtheritic prot'eaa may fiprcnd otcr a larse ox- 
tent of HurfiM.'e : tuid tht' layuni uf ui«iubriuic, constantly moitttcDcd by tbo 
discharge, undergo r.»pid decomiHwdlion, and |dve uut a most ofieueive 
gangrenous Btenoh. The genend syraptoniB in aucb casCH ore very severe, 
and the piktieiit utaially taiuht niptdjy frum exhauatioo. 

Iul1iuiimiiU>r>' compUcatioim Kometiuiei* arint iu the course of diulitlie- 
ria. After the opemUon of tmcheutoniy for uienibnuioiK cmuj*, it ix un- 
|icittium(el>- far fi<oiu uucomuQii to fiud tlie tcmpci-Hture rise to 1U2° or 
103^ and to discover, on examiuAtion uf the clieflt. nil the signs of ande 
coiisnlidatioii of the liuig. Somvtimoa, however, th«! jinhiionary losiou i« 
on rnrly contpbcAtion. In any case it gr<t>jitly Icswus the ehild'ff chances 
of recovery. 

Inflatiiiiiation of the perirardium and eRdncaiT]iiini are occntdonul com- 
pUcAtiotiK of the illuoRR. Pfiriparditis oiTuiTiiig nlonc wUI probably be 
ovcrlookotl without a carofid examiuulioii of Lhv pi-vcordifd region. Kudo 
carditiK also may give rise to but fuw »ymptoiii!«, luid is ofuii oidy di»- 
coremd on examination of the body after death. We mu«t, however, be 
on our guard, aud avoid attributing to cii<locarditt9 the hn^njatouiatoufi 
beotliug of the mitml vtdve duncribinl by ParroL (Sue page 546.) 

When a thrombus forms iu the heart, denth may occur either suddeuly 
at the moment of formation of the cnagnlum, or gradtudly after au interval 
nf much auuety and ButTKring, Uaiially thu Hymptoiiiti appeal- quite sud- 
denly. aud ata time when the child k^^um to be yoinj; on favourably to cnu- 
valeaoenoe, or ev^n after reeoverr ia (or advanued. If tht- fommtion of tho 
dot doM not bring the catte to a sudden tei-miitation, marked dyspnoea is 
one of th« earlieitt Higoa of tlie nccideuL 

Dyiipa<i'a iiriKing fmm want of blood ill 13io pulmoDary circulatifin is 
shown, an Di: Kichuidaon has pointed out, by «yui]>tou)B very difffirent in 
<:haKtctcr from tbo^ dtiv to an ulMtructed hir;}-ox. In the first cow, vlr 



tbotiL^ti the Vn^utliing in bit)our«], IJie lunpH nvo full of ixii- ami may even 
he tIint«nclod with it eufiiinently to prcMluco iii the ^ruutifjer iiubjects a peco- 
liai' |>romitieDct< in the anterior ptu1. i>i tlio chi-jtt. Tb^ arc no tdgna of 
inijierft^t ni^ritionnf hlood, bul nil itiesriniitouui indicate obstrurtinn tnlbo 
circuUtonTUrrpnt. Tliiiit tlie lijM niid (.-lieekfi are blue ; the jii^lnr vfiw 
diBtoDiltd : Uie Iicart-impuIsR i|iiifk, fweblc, »ikI irreKiJai-. Tlio body ia 
colli anil imie ; it zany be msrlili^iJ. esix-rially »t tbe eictreiuitieii ; and there 
in intense nnxietv mid nonstmit tuivurneiit. Wliwi death ot'cura, the heart 
eeflaen to m*t Itoforc tlic i-ispiiiitonr luovomeattj Lave come to an eud. 

On the ntttf^r )i.iiii), wln'u npn<ipn ncotii'ii fntin Ur^iigcnl obcitrurtioii the 
svnjptomM lUl \to\nt itt ini|x-rf(«'t (u-rtitinn of 1>1(huI. Th* siirflUM) of Iho body 
in dkiHky iiwtt.-^! •>{ p>ilo : Clio h^-iirt-Kountl^ oi-c olcnr ; llio canliac ioiptilse 
is fffblf but mrcly tiiniultuouH ; tbu luu^ art- c(»uf;tBtt.>d but not cmpltyse- 
matous ; tlwrt- it* gwiii rm?<Msi<jn of tlie epigaatriuni unc] Moft y-Artu of the 
ebest at eiu^h iuMpiratiou ; tiia mufloleH are cnuTaLuKl; and the lu-eut^iiiig 
BtOpa before thv luuvciuvuta of the lit;nrt cetute. 

Huddeu di^tb in cbia iu moHt cii»l-!«. probably, to the rapid tormatioa of 
■ dut in the right aide of the IiciltU It may be abio the umaequence 
of pimlysis of tht oartlitw brauoliea <>( the par vagum ; but in cnses whtre 
the oudiUn end hiift Ijct^n iittribiit«il to (hiM i-ftune, n gniniilar dpgeneration 
the cardiac musculiir fi\nx-« nitb Kuftciiiut; of tlir whIU ami dilntalion of 

oavttios hfut lx>t<u disoovort'd ou eiLn<ful ^'XHuiiriatiiiu. •Irfydcn Rii;tKi'»t8 
flint tba <»rdiiK' failure ia tlie result of tliene chiuiRCK Accordiuj^ to this 
obserrer, dangerous weakneM of the bpArt from tliis cauw is iiidirat<^<l by 
gallop-rhythm of the heart-eoun'U with weakne-it) of tlie inijiiilsi^ luid irreg- 
ulai- trr-umtouR oontmctions. Vomitinjf, due to a rv(1*otioii of the diittui-b- 
SDoe to othur partH of tbo ]>nei)mo{rwitrii! ufi'rt'. indie ntt^^a that the daof^ ia 
pnwgDg. Other ol>st*rveiH liavo noted precordial distresa, extreme t\y»p- 
Utea, suallnesa and irreguhritj' of tlie pulae, and attat^kti of palpitation 
aU«ni»tin)f with nlowimMtt of the pulsiitioiin. U. Weber has found t£e putse 
fall to tireuty-<-iglit or even iiixtvi-u bwtUi iu the iiiiuute. 

In a eei-tiiiu proportiou of canifs of Uiphthi^riiL eouvnleeccuc^ in inter- 
rupted 1>y the appearauce of paral\'tic lesione. The Erequeucy nitU which 
tluA cx)mpli<*^tinn in found to occur bait lieeu variou»ly e»tiniHted. Probabty 
it depemU) in nomn mmuiiire upon Ibe clmnurter of the epiileiiiic. The de- 
groc, too, to which the nervous system is affected is siil>ji'ct to jrrcal 
vmrioty. In Homo caeoe ibe lenon ia so triHiujc a* ecarct'ly to attnu-t atten- 
tion. Iu others it aroouuta to well-detined and geoenil loss of power. 
Taking mild and scvera formR (o^etlier, Ibe jiroportian of patients who 
sitSiir tT<na the complicikttoii ia |>i-i.^bri)>ly uue iu e\-ery leu or twelve CMM. 

Diphtlioritte parulyuLit in not Umitetl to coscit iu whleb the throat ni&c* 
tiou tuM bMsn sevens. TIiu tdi^btt^T fonuY of the distemper aiv ax liabb- as 
the more aerious fonns to be followed by the nerTO-leaion. Nor ia itn oc- 
correiice determiue^l by the tteal of tJie ilipbtheritic muiifeHtatiou or the 
proMUJoe or al^Heuoe of nlbtuuiuuriu. Il may follovr iu cw^ies where the falHe 
CMrabnne tuut been UMiiti_<d to the sldu, and in etuea where Hlbuwiiiii ria 
has sot b«en otiHc-rreil. The period at which the paralyaia ap]ieiLrs is lUeo 
aabject to variety. From au niinly)«i>t of sixteen c-hmp-s Di*. Abercrombto 
found that the pamlytic coiaphcntioit mi;;bt np^K^r from two to fii^e weeks 
froui tlie bej^nniii^ of the ulocte. Sitiiue hun uotioinl it lu en,rly as the 
BTCoiid or thini (lay of tbe diseaHc, but tftotca tliat it fp-uemlly toniCM on 
trum oue to two weeks after the diaappearance of the fat>«e utenibi-oiie. 
Aooonlisg to tiiin obaciTer, when the ]KUiuytie symptoms ap|*ear early 
mriT'j develop gmJually uud i^u-uihI aluwly from uiie p>^t to 

W)ii<ii tli« onset is rutAi?iie<l, tJi« dflrelopiaeut of tbe {laml^c pbcuometia 
u( taiu'li awn m]nd atid rOf^ilAr. 

TUo motor )(>uiuu m&y b(> pri^i-^ilo^l l>y meraase of liuiguor and irritabil- 
itr of temper. I>r. UemiftQu Weber has Dotioecl in many casoB a maiked 
(limimition in the ntpi<Ut,v of the pulse. The pn^al^'Elis is trmiiDelrical aa a 
nilfl. UmnJIf it l>et;^ii( ritWr by lowi o( powei: iu tL« soft [Jiilat« «lid ptmr- 
ynx or, by whAt ix oqunlly ■'ommoii. piinJjKis of ii«ooiDiuodataon of tbe 
cjQ. It is noticed tbiit wheu tbv cUild nttfniptii to hvoUov iw coiigbB riu- 
leiitljr and fluidit return tliroimh the nose. His Toico has a nasal quiUitjr 
uid b« imorps in tiis nleep. If t)ie patiiuit in uUI enough vf« can Bsofirtiua 
by iitspcctiou tluit be btu uo power of elcvAttUff tb« uvula, and pvrhiuis, 
a^o^ lual' Lbi^rt^ is moru or li-«s luiiuttLffiiit of tlic fuucoB. If tlic ol-uW 
mUKClvs toe affvetvil tbe cbiltl cviuplaiuN tbut be »e^« duuble. Kntdiug is 
difficult or impoaaible, and Bonietime» there is an evident squint In rare 
oaaea there is teiuiKtmrj Uiuduesa. 

W'bea tbe phar,\ux i» lli«t affscted ttw paralvBis luar remain limited to 
thin piurt. If it bo complote, the power of swaUowinj;; is lo«t and iood can 
DO louf^r be ]iro]xtlled down the ^;uUot The food btkeu i» found to col- 
lect iu a pouch formed bj- yielding of the trails of tlie cKHopbagus. In uich 
owoa Doiuishment baa to be ennvejed to the stoiuneb by meobanical meansL 
Tbe nae of the stomAcb-tube ift of the grcatettt scnioo in tltew caBM. both 
as n luvthod of miuntoiuin;; nutriiiou und oLw uh a mooon of preventing 
the «Dtnu)ce of food into the glottih. From tlie pbtu^ux the pandrsiB maj 
Bprcnd to oUier parte. 'Die tuogue iiiiJ h\)*i luuy iM-conie affecteif ho that 
the child diibblus aud tfi)f«cb m ^vutlr iutt-rfi'red \vitb. Loas of power 
may aim be noticed iu iLe liml^M, tbe ui-i^k, nud the bock. Of Uie limbic 
tilt* le<^ are ii(Y*^rttd tnoro eouimouly tUau ibi' amiiv Tbe [utrnlysis nlmuBt 
inraritkbly takefl (he (omi of piunphgia, for even if tbe veftknees is more 
marked on one side> it will be usaally found ou ezaniiimiioii tliAt the side 
which appears to bo sound has not eutirulj' escaped. Tlte motor paral^'us 
msT be s<>ootiiptuiicd by some disturbAooo of iwiiHAtioit. In rare ciwea ood- 
trol over the spbiurtsrs i^ lost. Pnrvlyaifi of the mtpimtory muscles eomci- 
titnes occtira. Tliere is then dy^mov : munta collects in tlie lungs, for 
there is no |mn-rr tn cough it up; niid tlie rhild uwiallr dies suflfocatcd. 
U the diapbni;^ is paruljt-svd thv cIuIlI hss uttA<:ka of d>-»pnu:B. comiiifr oa 
at tbe HlightnU excitement or ubcu uu attempt ix imwle to cou^ IX'uth 
mar ensue in such an attack. The must mudenite catarrh in suob a con- 
dition adds an adihtional eb^ment of (btngFT tn the caso. 

Beaidea tiictw forma of motor k-jaoti. suddeu death, attributed to pandy- 
Kb of the heurt. has been slrendT referred to (see page 99). 

Diphtberitie para]>-siB is fatal only in cxcepttuim cases. When death 
oocuta, it is usually the consequence of vorduc thrombosis or nrncope ; 
le^ ooiamoQl,v it is due to impaired uutritioii Ihrougb diflicul^ of nval- 
lowing, or to nervous exhaustion. Recover}' is the rule, otid the ra^iiditjr 
witit vrtidi this takes place is T«nr Toriable. The course is much Hiiorter 
in caaes irttere the paruysis is limited to the inlatD. This usually panes 
off IB a (ortnigbt (ir three weeks. TMion tbe low of power becomea |^- 
eral, a ear* is eflbctt^d with much greater difficulty ; but even in these cbbss 
it sddom laBta longer than three, or at tbe most four months. SooNtiaws 
the limba reoorer uieir power rery rapidly while the phoirnx imuios ob* 
stJBHtriy paralyzed for a oonsidsrahle longer period. 

DtagjuMM. — Vklum diphtheria give* rise to wvU-moikcd sytnptoios, its 
detectioB ta easy. The toogh-looldDg (.Tny or (awn^oiourtU memhrane in 
tbe throat, the reduces and aweUing of the fauoe^ a&d tbe enkxg«d aar> 



Ticftl gUtvla nrc suffici«ii1]y clinmcloristio. Id tounllitu the uvula is not 
flwollen, and the wliitiah cxuiluliou or<-Hi))iug the moutlis of the crj-pts, 
and sometmieK apotljng tlie surface of the tousils, in \f.ry difl!erci>t in n[>- 
pearanco from the coniostent false memhrann nf dipIitlif^riH. It ncror forois 
a oohcreDt lajer, aud never inrihlfiii the aacca or tbc Inryns, ^lufcover. 
in quiaMir, idtliuii;;b th« swollen toimila cm lie ft^U e!ttei'n:iUy, tlia cerrind 
gUmlti are sL'UIom Hiiprwrinblj enlarged, If, iii di|tlitliepi.i, thn cxmliition 
ia soft and pultaceous, instead of being iTuliereut und touf^Ii, thc-re is »liU 
«ulAr(;eoieiit of tlio Riipni-tioml cervicjaJ ^luuilft, nud the {.'niimU symptoius 
itidicutfi profouud deprc-ssioii. Auy tiimkinci^ or wetikuetw of the voice 
iniplios exteniiion of the inKainnifttion to the larynx, aud points unuistak- 
abg* to diphtheria.^ Tlie dtfBciilt riuwj) ttt detect, are tlinne in which the 
throat iJfecticiii is iiiiperfectljf developed, or Id rIow to nppear. At (list, 
nothing may bo noticed but rc(hiP8s and «wdiiii;» of tbo fiuu-oB. ■with some 
disooimort in swallowing. Iq tnidi caacH until the fake mcmbrnne np- 
peors, we cannot aay tbnt we have not to deal with nn ordinary intlanim»- 
iiOTj ttare throat ; for although the weaknesH and jmllor of the patient aro 
nnoU^r out of proportion to tlio nppoi-cnt mildness of the local affection. 
uo poidtivc infci-euco can bo drawn from thin diefiTpaiic)'. aw hoiuu chil- 
dren are more depressed than utbem by a bifliiig iiiliuetit. If suuU a «od- 
■dition be met with at a time when diphtheria is known to be prevalent, 
ve abould ret.-urd the syttiptoinn witli tniK-h apprcliension. Indeet^l, in any 
CMe of Kpre throat, if ('ulari^ement of the gliuids of tho neck can be di^ 
covered, we should u-ithlioUl a positire asHtirauoe tbat tbceompkint is one 
of httle coneeqaeace. SonietiniCB the appeai-aiice of albumen in the urine 
cotnea opportunely to clear up a doubtful case. ScmietiiiieH aft^-r tlic tei> 
miOHtioii of an ill-defined angina, the occnrronce of para]y«i« tlirows a uo«' 
tight upon the pa^tt indi^jxi.titiO'a. 

Lurngeol (hphtht-ria. or membrunouB croup, may Ijc confonnded with 
■triduloiia laryngitis, with abwceHs of or about the larjTis, or with retro- 
pharTii|;;eal suppuration. The distinctive pointH between these diseasea 
will W referred to in the chapters treating of tlieao affections. It is \k)s- 
sible that u furcij^ budy in the nir-pnssages tnaj' bo mistaken for croup ; 
but the attack of dyspuojo produced by this ineauH comes on quite sud- 
denlv and follows at once upon an attempt to swallow. There is spas- 
modic cough but no Loarseneiw ; and the tir»t paroxysm of suffocation and 
cough is luuftlly mcc«edet1 by a period of quiet in which, for the time, the 
breathing i» fairly 9tmy and tlii> chdd seeme to be well. 

It ia rer^' importaDb to be able to discrimioate between caaes in which 
tracheotomy may be expected to succeed and those in which no nerraa- 
seat gooil can be antjcipntecl fi'otn the operation. Dr. (ienrge Buelianan, 
of Glasgow, 'las pointed out that in crts«a where the ai i-passages below the 
point of olwtructioD ore free, and (ho lungs ore in n normal condition. 
there is great Teceaaion of all the soft parts of tlie chest. At each uispira- 
tion the intereoRtal Rpaees fall deeply in, and the epigastrium fonns a deep 
boUow. If, on the cuntnuy, the smaller broni:hiiiL tubes are full of mucuu 
or iliphlheritic esudatiou, the muvemeuts of the che>tl-wall are impeded. 
and the chest is pulled out so as to resemble the distended thorax of 
chronic euipb.>'8ema. 

If the patient be aeen for Uie first time when the paral,i-tic symptoms 
havo decliuwl tliomaelvett, the htstorj' of the attack will deohtre the nature 
of tlte disease. Ev^n if, aa aometimeB li.-tppens, the throat nflVclion has 
been too aUght to c»>nHlihite a regular illness, we shall tind. imdiably, iUttt 
other io«inber!) of the faoosebold have suffered from diphtheriii, nud tivtf 





iu tUu diilil ItimwU, tui; ^ga» of ^iieral uti-te-Iesiuu Uavc Ijeca pn <.-f'<lDil 
hy a uuail tdbv uf voice, sotiifr trouble in swuUowiiig, und Ui« cccBitioiutl 
return of fiuiils tluxiugli llie nose. 

Aocording to M. Londrotun-, if ft child who is convnlosceot frooi tlipb- 
tUem Iw^as to suffer from aiutofcH of d^xmitEa escitetl bv an attempt (o 
cougb, or by uiv mudl vezatioD, we shoQld mspert paralynit of thu ■]!»• 
pbragm in the n^nco of bdj tDors ovidaiit exploDfitiou of tlin ilistn:>»nng 

F)rog»onx. — Gren in Uie laildert lUAaclc of dlpbtheria vo luimt be 
ctuitlol in Uut oiiircRtuon of our opinion as to tlie pi-obnljle uwue of tlie 
mn«e& Intlucd, it ia witter to express no opinion iijh^u the mutter, Init 
to confine ounKrlvtii tu tT|Njrtiu^ the diulv proj^'ciM of tlio cunc. ami Hjieob- 
iiiR eht-crfully so long as no H\-uiptuiiiH hi-Imj iiii)ic»tiv(> uf ilujig^r. W)' can 
never foel ccrtmn Umt the inflamniutiou muv nut spread to the Intrnx, OTj 
tbut, other ill coniteiintnciceinsy not «u&iie, lutwevrr fnvoiintbtv the diHOUfr] 
may app«ar to be going ou. Osu^on in progno«;i ut o«]>ociaJly neceMnat^r] 
if t\u> epidemic IB ft Hvvere one, for outbreak* of the <1urt«niper vary 
grewUr in tlie severity of tj-pe of tli« iUuees, and iu some the mortality is 
tuucb ^'r«nt4-r thiui it. is in others. The age of the pnlienl is also aii liiipor* 
tiuiL i(«>iii tu biko into eonsidenttioD, for a young cliild bas Umvr cluuices 
ol recover^' thftu ou older on«. 

DiflfTPnt doncera ore to lie apprt'liendod at different periods of the di»> 
enae. Ihiring Uie first week n-e dread lest the iufianunatitHi Khmild 
mmnd to tlut ]ar\-nx, or le«t the child idioald die (mm septicEmia. We 
tbcnrforu uotirc airtjully tiie ebacacter of tlie brt-'atUiuj^ aa^ tbo quality of 
the voice. If the breathing beoome ehriU and the iiii>v«montiiLiboiure<i or 
the voice g*t weak or husky, we «iu have no duiibt that the Uiynx is Ix*- 
comiu^' iuvob<'<i. So. tdeo, in caaeft where the (aliie membrane is thick, 
pulpy, and ]iuti-i-sc(-iit the ito-urreuce of shivering or n sudden rise in the 
t^^-mp'i-ntiu-e, with a dnll yellow lint of the (ace and a rapid f^-eble pulne, 
makes ue fear that the blood ia bocomiug poisoned by absorption fn»n th« 
afTeotuHl luuoous uieinbnuie. I>r. ilscoby boa pointed out that in itn^ 
diphtheria eepticwmia is eitjiecially liable to occur. In this form of the 
disoasp, tb«reioi«, the regular use of dinnfeeting injections is impdratirely 
cuUod for. 

After the fimt nx or Hcveu days the child is iu danger of death from 
nrnoope, from clotting of blood iu the heart, awl from inttiuiimalorr com- 
{Uinttions. At thi» time ve t-nrefully imtch the pulse. If this fall notably 
iu frequency and atnuiglh, (-t<|MviaIly if at the aiuue time VDiniling occur'] 
and be often re|>e]iteil, tJie diinger in imiuineut. At this period of the dt*-- 
ease birmorrhngeH sometimes eome on ns a n-sult of profound blood coD- ' 
(amination and ur« vorr exhausting. Other sigiia of biwl niigurt' are : a 
very feeble frequent puUP, cardiar dji-stpotPJt (see pnge ^), geuerid Hwell- 
ing of the uec-k. great profiti-atiuit. lUid dnlinmix wnudenugs. Albumi> 
Quria, unless exceeeive, is not neceesanly ft grare sii'mptom. 

Wlien tlie iliphtheritic eiudatinn invwles the trachea the danger is vc-iy 
serious ; but if ihu u]>emtioa of tmcheotomy be performed iu time, and a 
Duufaed retjnction oi the ehwt-wall indicatee tlint the smaller ttiben are-' 
free below the point of olxitniction, and that nir, if oilmittecl, vnll Ixi able to 
penetrate to the alveoli, reciveiy is far from impoimible. After the oper- 
ation, sacceiw depends chietly tipnn tlie child'ti nt|)ability of diking and dl- 
geBting liiit food, and upvu the luugB rtmoiuiug (roc from pneumonia. If 
uiere is difficulty iu admiuiateriug nourirsbment, the rhUd can he still fed 
thnnigb the stomach-tube ; but loss of appetite usually implies feeble di- 


I power, and the prospect ia not fsTouruble. 11 pueumonia occur, tbo 
ii* gloom/. 

Aft«r tlio «ud of tlie Moonci or thinl week nernius ffjm^rixinm may 1)« 
exp«ct««]. In thc'si- tbe prognosis is fftvouiiiblc. It onlv bocotues Berioux 
wben the lesion ia widely dimu^d, when idl tbe uuHckti ol deglutitiou are 
aflcctod 80 that Bwallowing becumeH iaiposflible, or when tJie dinplim^^ 
and raspiratorv iimscks tiro attnckod. No cbUd. howfvi^r, sliould bo ul- 
low«d to die of storvstioii, for nourisbi&ent cim al^rajs be Administered at 
regular intenndn tlimu^h tlie fltomach-tiibe (iafi»pd through tlie- jinme- 

TreaHHenl. — I>iphtJi«rt:\ U an, iiifectioiis diHenne, and Die onliimn* pre- 
eautioDS must tlwtri?forc bo tnk^n n^iittt itj< uprfuuL Tlwt sick room should 
be divested of carpets, raps. curUiimi. and Kupcrfluoua funiit\uc ; and 
proper meosorca dbould be tidii?n to LU<<iufei.-t nil disctuir)reH from the pfitieot 
before removal 

Tbe child niuat 1m kept quiet io bed. It is well to place liim iu n tent 
bedstead and to uuvelop hiiu in ku atutoKpltcre of Kt«am impn-t^ntt^d with 
th^luoL creusote, or other disinfectimt. ThiHDiiiy beniuHt. roiivonienUvduue 
Iw tbe a»e of tbe " croup kettle " deHigned bv Sir. K. W. Rirker, on the 
principle of Dr. Lee*» " steam draii<;ht inhaler.' Creattoteor carlxilic acitl 
iiMiy M> a<li]iKl to thi< water iu the kettle in the proi>ortioii of twenty' drops 
to the piut, or a wittirated ftolution of tliymot can be made um> ot So 
many technical matters have to be attended to in tbe treatment of Uieee 
owes Uiat what<>Ter \>e the age of ilie child the asHixtanre of a HkillFtl nuise 
18 iDdispcniwbU:^ Auiateiir nurwng, aeldom if ever Katiufncloi-y, is here a 
senous disadrnntaf^o to the paticnt> and introchices into the cam an addi- 
tional element of dimmer. 

The treatment of tlie disease rnmpriBeii general and lo«J meaHures, and 
theae are of aliout equal importance. 

The g(Tnc)-al trvatuicut uonttinttt in einployin^^ every iiie;inh to KUpporl 
the fltn-ui^li of thf chihl, ao as to eiiiiblc hiai to stnife'^'k- succt-Msfully 
against the (.'xliHUKling influenco uf tlia disorder. The jiittieiit Hbuiik) be 
su)>phed «'ith food of a nourishing and digcfltible kind. Strong beef es- 
eeiir*. yolk of egg, milk tliirk«ned wiUi Chapman's entire wheat Hour 
biked in an oreii. poun<led uiulerdoue meat mad^ fluid witli strong meat 
jni^ro OF m4^nt essence, all tliem are very useful. Aloohol inuat not be for- 
gotten, aad will often have to be ^ven in full doses. Old brandy or 
whiskey, with or without yolk of egg, abould be giren at tlie first wjin of 
feeblenefis of the piihte. A ehikl live years of a^ nill tnkn with brnefit 
thirty drops of ftood brandy every two Lours. In infants white wine whcj 
given frt-cly is ren* useful. In fjivinf? »tiniuluiils wo must bo guided by 
the state of tbe poise, or in infants by the eondition of the fontonelle. As 
long as the pubf- is lirm or the foataiielle little depressed, alcohol is not re- 
quired, wbon thf puW gctn outt and comprewtible, or tlie fuulanelle sinks, 
atiuiuliLuts must be given without delay. It some cases they will be re- 
([uired from tli4' first. 

In the selection of medicines preference sliould be given to such as do 
not canso depiesaion. In iliphtheria there is n tendency to failure of th<* 
heart's aetion ; and tli» tendency is likely Io be favoured by tlio use of de- 
pnasiiig remedies, euch rm the ealicylate ot sodn, whi<4i has been aomctimca 
leoommended. A simple fcbrifii^re mny be given wbilc the temperature ia 
hifilh and tbe akin dr^- : but directly the strength shows signs of failing, iron 
and ijuinino sbould be rewrtf^l to. The pcrrhloride is iKrhapn as good a 
preparation oh any other. Ten or liflccn drops of the tincttirc may bu 
gnren with one grain of quinine t-vrrA' three hours to a child fire years o£ 



Bt;c. Mucli Isr^r Amt^ of tl>e ilrug iire otttn rcoomuK-'iided : bnt ,vouDg 
trbildroii viu^' great!; id their CApa«Htv for benefit iiij^ liy diKlvbeate remalio^ 
mid in weakly Kubj<Ktt« the «rtomach mnj be readily aerniif^il hy iiii <-vo(rw 
of tUe medicine. Kow it ia of the tlrst itui^torlaiire to tuaiutiiiii tli<- ilit^usUve 
power, u iiKx>i)iparabljr tlie beat tonic for ii cLiltl in uoiiriKhm^r (txxL 

iDstaod of <|uiiii&i:i, ohlorato of potuuli in oft^u eonjoiuGd uitli the inm ; 
but tbifl remedy Bhould bo airen mth rautino aa it has a dt-ureitftiug effect 
on some children. It ia well to begin tlie treatment with ii itwtxninal 
|)ur{i!o, 8uoh a» grnv powdor vitli jalnpincj but the apori(>ut oectl QOt be 
af torvArda rcpciit«l. 

Li tlie uea of local rvmedie* vre hare to fulfil three mdicalioos : toarre«t 
tlie Hjii-ead of the fahte membrane ; to pnnuote its r<>tuova], and tn prevent 
8optto-ii niia b-om abnorption of putr&iernt matt^-m in ix)i)ta4>t with tho tiitmiefli 

Miuiy Lueiututva Imve been employed to pnTvnt the esteanoii of tlie 
lociU lesion in Llw tliroat. At one time iitxoDg cauteriiong agenta n-ere 
retuirted to tu efTect UiIk purpu(«<, suuh aa the solid nitrate of ulver, 0()ual 
parts of atroog liydrocLlurtc acid aiid honey, and the struug; nolutioii of 
perchloride of iron. TImi rf^eaiai tiss of these agents is now nlmoHt 
univ(<i>^dly ooudctiiiii^d, but ouo tliorough Bwnbbiiig of tJie U^uat is Htill 
AdToc&t«d by eotan vmU^n. I hAv« occ^asionallT employed equal jtarls of 
Htmng perchloride of iron solution n,nd (;lyrenne, and hare thought that 
awd efncii'ittly, oni'e for nil, the applicHtion haii befti folloirecl by benefit. 
Many uTit^w, however, dopi-ecnte the ana of Iheac powerful ag«nt« ; aod 
oertaLuly, idnoc i have abauidonod tLt;ir employment, 1 luire not found tbe 
(1iaea»e leBH tnictuble or more dauK<;n)uii to life. 

To promote the Ut{U(-fn(.-Uou or rfnio\-sl of the false membrane maoj' 
Agents are employed. liougb tearing sway of the diphtheritic exudation 
is injuriuuM nrt vn)\ tm useless ; Imt gentle measures to further il« di-Ktruc- 
t]<Hi are decidedly beneGoinl. To be of Mrvice. howcwr. tlie u]>]>lic»tiou 
must Im> used rewatixlly. luid t-au lie applied witli [K'rtec-t efficitucy in the 
form of A i^piTiy from one of Siegel's 8)>ray ]>rotluiri)i')i Lime-water, uloiM 
or with cJirholitr ni-id (twenty ilroits to the ounce of lime-water), li<j. potasBK 
(twenty di-opato tlieouuco of wnt^T), boravic acid (a scruple to theouiicc), 
Ucliti acid 1 twcDty-uU t?r<uuti to th« ounce), bctizoskte of soda (one scruple 
to OIM drsobm to the oimce), all theoe iiro of Hcrrire, and the addition of 
gfyoarine (half a di-nrhiu to tlie ounce) increaseti tlte effiracy of the solu- 
tions. Lotions of chlomtn of potimh (ten gminH to the ounce) tuid of 
■HUcylic iiuid (three or four t'luius tu the ouucu) ore pmised by some, as 
well lu ilry insufBaUouB of flour of aulphur, of nluou, and of taunln. These 
latter hnre, however, the disadvantage that they cannot b« employed witli> 
out diMtri-sftiiit; Uie patient If thought more dc^mble, any of the abo^t 
liquid prcpurutioiiH may be usi-il uitli a bnish. but tlit» mdhud of em- 
ploj'nieut iH diNtix-iwiiig, and eic«pt )M*rhapH lu thei'nM! of infants, prosenta 
tto special advantage. 

'l\m tliirtl indication, vis., to destroy the pniHonous produola of putro- 
C*oLion so as to prevent absorption and bloo*! conlamiuation, is partly 
a0Bet«d by the uss of many of the preceding agentK But beuides these^ 
special diHiufectoQta may l>c Epmved into the throot. such tm the solubou of 
cnloriuatiil ftoda or time dilute<l with water (half a drachm to the ounce), 
iwrmougaiiftte of potiuib (tive gminx to the ounce), nulphun^us acid. puM 
or diluted with an equal quantity of wati^r, etc. The cotufort of the pAtient 
ia also promoted by the use of the steiun kettle, ■■ alreaitv txx-ouimcudwl, 
and by warm appUi^tioiut extemallT tb the throat If iLe child be old 
enough, he may be allowed to suck lumps of ice. 


Ill jutml iliphtliortn. where aeptiaenuA is cHpociftUj to lie drencled, the 
tLorougli (Oeaii-ting of tlie naml fnma^w with a mikl diMuife'-tiiig whition 
should n«vor 1>« nmil;U)<]. T)in imiwrtAiic^ of tbia measiuv in tii»iKt<:-d upoii 
by Dr. Jocnhi. "vrlio n.-uuinmcDds Uuit the nroo^m eihoiild lie cnrriud out by 
Uie fotiot&iu syriiiKe wbt-rever practicahfe. FniUijg llmt. ao oniimifj ear 
8TTinf[8 «aii be miule use ot He dircwtit that tlio iiij^t^liuii Hliuuld be re- 
poatctl OS often as every hour, and that If the obfltnicted ii'istnln reHist the 
paange oi tiiiid, lUo cusrscr loutteiB tniint be i-pninved bv a pr(ib« or 
forceps. Dr. .lacobi KtateH that tiwm injeotinriB, (•ttli>i«iit.lf friiinloved, give 
grmt relief to the patient ant) rapidly re-duco tho size of the tiwoUeii ^lontlti. 
He advises u iTiiriii tiobilifiri of uirbulic Eicid (tiro to four gnuus to tlit^ 
otiDoe), or. if there in tii> ftiflur, of liiue-water. 

When the diseiiHe invtuleti the birytix the dniiger is nt oncA intnuDcnt, 
and the question of oi>einitiH-e iutorfci-t'iici^ liiu to bo couHidenvL In cases 
of lAnni^;«al dipbtbvriii i t nia metubrjLuuuit crouj)), tmcheotouiy is the otAj 
hupt! left tu us — the I'hilil'ii last i-bauco for hik life. Directly, therefore, 
we f«el sure that the ki^-ux is iu%-olved, the operution should be under- 
taken witlioiil unnecGHHnr}- ileLny. It iinist be ifnienibereii, litiwerer. tliat 
dnqiQOOA alone i» not always it wiifTioipnt iiidimlion for tliis 8ie|)^ Aa has 
bieo botoro ejcplainod (aeo p. 99). b\idityiiii<l labom-pd breathiner are some- 
timeff due to an impediment to tlK> circuhttion of lilood throUKb Uie luiiga. 
In «urh a caxe there in no wiuit of air, bikI oj>ening the larynx will bring 
no relief to tlie child'a di8tre!«R. 'I'lio iogn* by wliich the^i two very diflior- 
«iit coaditiouM ana iudi<.<Al«d have bcvn ulrciuly enumerated. When, there- 
low, wc notirai that the reaiHratoiy movt-tneiitH have iM-cximt labourt-d, with 
great receMsioti of the rpignstrium aud the Hoft partH of tlie chcNt in inKpi> 
ration ; that the brealhiiii; i^ hinaiug aud stridtuuun, thu vi<i<.'e whLfpcu-ing, 
nud the ouu<;h huaky luid stitlrd. tbe D|>cn>tiuD xhuuld be uu luuf^cr post- 
poDPiL Wi> have uolhiiiH to liope for in tk-l«y ; on the eiintnu'y. Ilie nirlier 
the tube ia inl roducwl into the Irachea, the sooner will tho rhild'a milferiug 
be rebcrDduud t he better be bi«proftpei-t of actu%. The Huuoeaa which often 
attauda tlw operatiou of tiucheotumy in membranoiiii croup ia very enrour* 
Bffag, and even in the ciwe of an infant we should not hemlAto to Iiave ro- 
oonrae to it £^-en at a later Bta^e, when the child 90oma to bo at the laat 
tptsp, the operatiou ttliould !«till l>e undertaken, for notliing abort of actual 
death cAu render it boj>el«aB. 

Ia perfomiiuK tb* op«ntiotl, if the (wphyxin is far advanced anie«tl)etica 
will l»e unnereMory. H the lividity is not marked, i^hlon)ronii ahould he atl- 
miuistered. and if the child be made to itihtde it gnwluMlly so tliat h« doea 
not breathe in loo large a \Mluino at firHt, the aniealbetii; rnay bo given 
witliuut fear. The detuila of the operation. ii» they come under the deportr 
mcnt of tlie HUTfjLHJu, iil-ciI not be here reft-mtd to ; more especially aa tbey 
will be foumi recorded at leugtii in all uurku on pmetical 8iir:tl<'<'^'- ^^ ^^'^y 
be oaiy remarked that the aize of the tube to be etnpkiye<l sh'tuld be tho 
Urgirat uhirli ciui be introduced witliout A'iolence ; that it ^liould Ix* us 
riiort as w (xuiKtstODt with mfety ; and that Iwfore its intj-oiluctiou the tm- 
ebe* and larynx mufit bo thorougldy eloaiuied by infyiHlucing a feather 
soolted in a warm imlution of carbonate of w>da through the oponing. The 
importance of thia [irtM^ution Ima been strongly ioaiated upon by uy ool- 
leBffue Mr. Pnrkcr in his well-knonii ti^atine. 

The rehef afforded by tho optratton is uaiiaUy eomplete. If the diffi- 
culty of breatliiu^ stilt rontinuca, it ia a eigii that the txacliea ia olwtructoti 
below the opening, and that there in prububty extension of the faUe luem- 
bn&e far ilown the i-Amitications of the bronchi. 




Tbo nftor-condiKH nf thrtw oiuieii is of tbo otmoRt impbi^juice, an succcfB 
dcpeuilfl upon judicious Hunting ninl scrupulous ■ttcation tu Htuall ^wiuti* 
of tivntruGut Our uLjoct ia to fiLmiiih n comitiuil supply of properly pre- 
piired air to tlie lungs. The utmcMt (»ri* has therefore lo tnt t»k(>n to 
nuiintain thi^ in!i]nr<xL air at a Buitnhle temperature anil (1rfp^« of nioi»- 
tuFu, EUiil tu Kco liiut Uiu tubu tB kcpt in plucv. Mor«OTcr, the strcof^tb of 
tile fliild lian to be supported, autl tli» ti^atiuvtit of the cotuititutionnj dis- 
«Aae to be continued. 

Tlie child uhould reaiaiii io bia t«itt l>edat«ad, in a rooui of tli« temper- 
ature of 70° ; aixl the vroui>ki!ttle must be li«pt in action on a lade table 
so OS to muisteii the air lie l>rcJttlii-iT. A di^nfeotaut ubould be alvrsys ad- 
ded to the water in the boiler, iw olrfiwlj* dir^t«d. The kettle n(ust not bo 
placed too near the bed. If the air in kept constantly HRturite<l with vu- 
])otir, till) cxevKS r>f moisluro ten<lH to dejircHK lh« rhild. "Mr. Furker's rulo 
is a i;;oo<i one, -riz.. tlmt we kIiouM lie puided by tlic itiiiount of tracheal 
i-et-retioii. If lliih is Humll. thu luuuuut uf stcuui onn be increasetl. 

The win(l-pi]^>f and tracheotomy tulx." must be kept patent Free ac- 
i-j-elion i» to be deHiretl, but thin iiiust not be allowei] to wciuiiulate ao as 
to iutcrfore vith the {jausii^i.- of air. II ia importADt to A)<ply weak alkaline 
aolutiona, auch aa the birurbunatti of tfoda (Ivn to twenty tjruins to the 
ounce) with a hand Kpray-pnjduL'er at dburt intomdii, tio Unit the iulialed air 
may be nntumted with the Bolvent, The apmy at once producea free accre- 
tion iulo tho windpipe ; luid the repeated uae of lliia aj^it prLivcnta the 
mucus from ai-cuniiihitiug luid beooiniug insinasated ho ns to block up the air* 
|ia6Wige«. It is ourioiiit to uotieo how tlia dty uiucouu nxiubiiuio become* 
almoHt iuataiitly reheved by tlua meaxi& After a few minutes' ubo of tlio 
n>niy, a feather soakeil io the aame atilution must be paiiaed into the trachea 
through tlio silwr tube, ao na to nlear away looiiened luembnuie and muoua 
The iatroductiOD of the fcntlior c-nit^>M iipftKinodia coiif^li, but tlii>i ia not 
to be regretted, aa the violent expulave uctiou usuuUy lelievcit the {lalient of 
large portions of membrane, and greatly aidH In clearing the tnu'hca. If 
aif^iiH of obstnieted breathing are uiitieed at any tiine, we may ■■itncliule 
tliat L-iUier the tniL-bi»i or the trocheolomy Lube ia becOtiiiLg obstrocted, or 
that the tatter ia diapluccd. MoABurvs mUHt tjicu be token at ouoe to rem- 
edy the fault 

The inner tube ahould be KtnoTed ereir hour or two am) deaued with 
n feather tUpped in the muru olkaliQe aoliition. Tlie outer tube will re^ 
quire (.^ponlng ouly once in the twenty-four houix. ^'heu it is removotl, 
advantage shotdd be taken of the opportunity to pnsa tbe uioieteued feat her 
upwoiils into and Uirough the glottiit, ao aa to clcur tbo upi>er part of the 
windpipe. Ai lliia time, alsa the wound can be exHmin»iI for any un- 
hcialdiy uppeaninue. As a ruk-, the outer tube con be easily taken out uud 
repla<:ed, frir the tiasuM around the opening aooa becoioe uatted to- 
gether by iiitlainmatory exudation, and the urificD remains patent after 
tlie tiilio is willidrmwiL After each cleaning tlie tube ahoald Ixt replaced 
by another uf lUffereot Ungth, so that tlio child may wear a ahort and a 
long tube alternately. If tlic tube be of BilTer. it Khuidd be cxuniiocd for 
black diiicolouraCinna, an these are due to morbid aetion at the curre- 
apondisg part of the wound, and nnll therefore, as Mr. Parker hoH pointed 
out, be ^ten raluablo guidiviiu indicating the {Murts to which our atteutaon 
should lie directed. 

After a few dayii, when freab niembnme has ceased to be formed, we 
may make trial from time Lo time of the cbild'a power of breathing through 
Uie glottis by ckwoDg the external wound with a linger. At 6nl uie 

breathiiig is labourMl, Mpeci&lly iu iuHpinitiou. but. in most cases tiie 
glottis som becomes accufitoined to act again tut &d nir-paaaage. 

MTIiile the nbore tnutment is being carrkd out, Uie 8ti-eiigtli of the 
child miuit Iw 8upport«(l by jiidieious feciling. Strong mcmt ««»eaoe, 
potiDcle*! meat, »ggs, milk, stratif^ tiiimr. brothu tliiok«uetl witli armn-ruot 
or 8Ago, aud flaronred if <i(iaired nitli turnii), alioulil be ^vt>u at i-i^ular 
interrnU. Soitietiines there is diffii^ulfy in pHrauiuliii;^ tlie <-Lilil wiUiiii;!; 
to tako itufficieut uoumluiiviil ; iin<i tioiuoUnu« tbo {tower of swuUowljitT U 
inip«uz«d from pareuis of the mueclca of the phiujnx. Sometimea, umt, 
there ap|>ears to be Inwt of aendihilitj' of the ^'Inttiii, no that iLrticies of food 
taken apjtear at tlic wound in the nir-pipe. If uet^ewiary, tiierefore, food 
miut l»o iynivpv<'<) to the «tomiMrh by an elastie tube passinf; tliroujjh the 
now (sua IutroOu<.-tur> Chipti'r, pii(;o 15). U; this uitiOUH the putivut can 
be ied efficiently every three or four hours. Internal tvinediea, with the 
enwption of aleohol, are better diacontiiiued at this time. It ia wiser to 
limit ouriielvKd to the local measurers wliicU linte been ilescntiKl for th« 
relief of tilt) local diacaite, and to lrii»t to n-iruliir feeding and ali-oliol to 
support the Htreugtb of the piitieot and enable hiiu tii atriiggle succcisiful- 
ly agftinat the eonBtitutional disorder, 

The trtu^heoloiity tube nhnulit not be fdlowecl to remain in the tradien 
day longer tiimi i« nece4*»ury ; for besiiles that it \» not well to allow the 
lotos to eoiitiiitte a Ioti^ time iimotive. too ix-r^trteol rotentton of tlio Iitl)e 
may be followed Ijy ulcemtion about the wound, uetn'osiis of tbti cinsH of 
the trachea, and other iwcidents. In linally cloainrr the wound (^rhiin ilif- 
ficnltiofi are ROmntinieH met witiL I1ie riiill hiivin*; hecorae aectuitomed to 
thsnae of the tube, and having; a kocii recolleftian of hU siitTerinf^ before 
ita iasetttoo, ia often nenouH and u]ipreliL-UNivo uf a return of hiu dvHpuuta. 
Thia leiy dread luay be HutHcieut to interfere with the normal action of 
the Uni*ngeal TOtistclea Ilefore removing the tube altogetlier many at- 
tetnpta should be luw-le, by wiUuhuwiii^ it temiiorarily and cloi^ing the 
Opening with a pod of liiitv to acctiatoiu the child to bn^athe without its 
help. Hoshoutil be ali>o inudo toartic-ulnteinuler the same coni1itiona(i.i!., 
wtula tbe o[}euiug is closed), so as to liriug the muttcles of hid larynx again 
into action. 

Tha nccidoute wliieli often ioterfore Beriotiflly with tbe final withdrawal 
ol tlio tub© are : inflammatory hypcrtropliy of tlie xo^al conlr*. ndhcsdon 
bctwDt-n the conlfl, grsnuliitiouH f^^wing from the tracheal woiiutl or 
frxnn tbe posterior wall of the windpipe, parahsiH of the pcwlerinr rrico- 
arytffiaoifi muactes, BpoRni of the gloltia, cicatni^ial narrnwiiigof thetmt^hea. 
Sometime* it is only after much iLilhculty that the proper huiciion of the 
diaased larynx ia restored. Such ciuich arc, however, esciptiouivl. Usually 
afUir a few daya tho child becomes accustomed to du without the lu-lp of 
tbe tube and iU appreheuaions of a return of his dyspntea may be laid 

The chief daoger and common cniue of death after tracheotomy in 
memln'aRoua croup ia the occurrouec of pneiimoniA. If this unfortunato 
eomplica.tioo arise, warm poultices niuat be kept constantly applied to the 
chest, and stimulants must be given freely. 

If diphtheria of the external wound oceur, it is beat treated by a car«- 
fnl attention to cleanlinfiiM, and by painting the wound with a Holution of 
lactic acid (twenty-four f^'iuna to the cjuncc). 

In the poralyidii which often follows diphtheria the child tihould be re- 
moved to a bracing nea-side resideuce. and while there <iho\ihl be regnlnrly 
■bampooecl and be giwo baths of the Hca-wal«r. If a dip in the sea i» too 


vigorouB a ahock for his weakened frame, the douche may be employed in 
the house after suitable preparation, as directed elsewhere (see Introductory 
Chapter, page 17). Quinine, iron, and strychnia are usenil in these cases, 
and the child should pass as much time bb possible out of doors. Begular 
faradisation is of service, especially in oaees where the loss of power alects 
the muscles of the larynx or those employed in respiration. In cases where 
there is complete paralysis of the muscles of deglutition, and consequent 
inabihty to swallow, the child must be fed regularly with the stomach-tube 
passed through the nose. At the East London Children's Hospital many 
children have been saved by this means who were quite unable to take 
nourishment, and who without this help would certainly have died of in- 

When a thrombus forms in the heart and gives ries to serious dyspncea, 
the child should be kept lying doum ; hot bottles should be appUed to his 
feet and if necessary to his sides ; and diffusible stimulants must be given 
internally. Dr. Bichardson speaks highly of the liq. ammoniee (P. B.), of 
which a few drops may be given with hve grains of iodide of potassium 
every alternate hour. If the heart's action appear to be failing, stimulants 
in lurge and repeated doses are indicated. 



EsTSiPKLis ia not often seen in chiklliood attev tlie a^^^e of infauoy has 
pKWecL For a sliort time aft«r birth, hovreT«r. tbeie ftiipeare to bo n Bpocial 
tendency, umler hTouriug conilitious, to suffer horn Ihui HuriouH affection ; 
■Del iulyin^-iu hotspitalM tlie disease ik h uot utidimiliar oue. .Vmoiiggt 
well-to-do families urvxijM'lns but mraly Rt(a<.>l£H tbo infant, and in chil- 
dreu*s liDflpitolB, AYen in those wliere quite y»uu^ infiuitA are mliuittod. it 
is exceptional to nieftt niUi an example <if this form ol iniicJts. 

CauMOiiuti, — KrysipoliM is in oil (H8P« a ^onoiiU iU?h:'1i»v of which the 
dermatitis and it» etnisf!f|n<'nc(w wo nifroly the lociil i:<Kpression. The 
niftinily niottt ixinunnnly iitt'i-vtii new-born bitbicn at a time when jnierpeml 
fever vt prrvnlant, and ia most liable! tu hapjien during tlie first aix weeks 
of life. It in tlu'n apparently thn reitult of n. similnr RtTcction to that which 
attacks tlie muth<T : uuil tho illnosK almost invuriably hnH a fiiuU ifieue. 
AvRfinling to Truiuiseau. bpaides t'rj'ripoIuH. punilvnl oplithalmia and in- 
tnctivn poritonitiB arc common luider tli<> iiauie <!on(litionH, luid t)to throe 
di»eiwM» must be re);arded aa various mauifetttatiouB iu diiferuut Hubjecte 
of the mine morbilic principle. 

But bestdni 8po<*ial puerperal infection, otb» af^ncies nill act as pre- 
diepoons causes of th^ adection. DnheoUthy conditions gonerallj will do 
tiuB ..HMM the oomphiint liaa been known to follow exhaustiui; deraogo- 
meuU and disenue, such as chronic i3ige8tiv» troubles and the acute spe- 
cific fevcni. In uom(> vaac^ howerer, no aiicb tufliieuces can be <lisc07ered 
to have been in opemtiou. Huch a case came under my own o1}servatinn 
in my student ilaj-a. A hcjJtliy infant of a week old hiu] pre-al ditUcnlty 
in rplienut* bin bladder, owiiij,' to a vory nurrow prfpiitial oriiioe. The 
operation for cirouracixion win* ]wrforni<-il (not v«rj- wi»ely) by a young 
surgeon. BxleDHirc orjiiiptihuf foUowi-d. starting from the woimd. and in 
■ few daja resulted in the deatb of the patienL The child wsm b^ing 
•ackied bj a htudthr mother. The parents were of the poorer chuts, hut 
Memed oomfortAbly circuiiutttuicvd ; uud tlieir rc-niiloiiue waa cUian, and 
certainly preitetttvd no obviouM imtanitaiy couditiuux, Pusi^ibly in this 
and atnular caaea the eryKipehw owed its origin to tlio use of iuiperft^ctly 
dcBDaed inatruui«tita iu the operation. 

The txcilin*; c-ituse of the litTectiou is usually traumaiic. Tlie eiyeiiJelaa 
any follow thi' upemtion of v)u<4>iuation, iiitlaniiunl ion wet up aboui the 
umbilicus, a bum, or the incautiouo application of a bliuter. It may do- 
Tetop aroond an intertrigo or att.-ick a eurfnci? escorJated by the irritation 
ol excreta. Some time ago a local outbreak of erri>i)>elRs occurring b u 
ttcttlar London dintrirt watt tracetl Ui tlie uae of n violet powder exteiiHii'ely 
adoUerated witJi white nnsenio. Apparently i<.Uoi>athio caei-e <lo, howc^'er, 
wnnetitDea oocnr. Thuit. Mr. Stni;;uell bus reported Die ciiac of a luole in- 


fiuil^ agod eight ircoka, in wLom ft pittoh of cnr-«i}M-lAti iippunn-il ou ike 
fuTOlp and thence Bprvad to ihu fuc'«, arms, tiiKl trunk. 'Vhv cliUd liaJ Buf- 
ferea from no braiiM? or other injurv, and uuthiug objwitioiiable was din. 
covered in the sanitary £tale of the house in irbicu his pareuts were living. 
Oilier caaes of a dniLlAr kind are on reronl. 

It Heems possible that tha milk of a mother who luw 1nt«ly Bufli>>r»(] from 
etrsipelfta may comuiumoittA the diwase to hor mickic^ t'hild. Dr. Sohole- 
tielil iinH reported n casr in which a n'ontau ihirin^ a, idiarp nttark of «r}'- 
8i]>el«K of the face, rjeck, and w«lp, gave bhtli to a won. Att the hib(.)ur 
CKigreafled th« ct^'sipeloa gnulnally fiul(><1, and wlu'n tlie child vf»st bom do 
bBOB of redneas remained. Thg mother wa» niu^i-d not to nurse her 
child ; but nn the fourth day, fiH the secTRtion nf milk was ccmimui, site 
put the infant, to tlie broasd, Twplvn hours nftf miirds a red blush ay- 
pearcd on iho child't^ thumb and gproad to the arm. 'Has faded oud the 
opposite urm btcaiua ufrcntL'd ill Uii': Home way. Aftvrvriuds thti some 
ayniptom appears) cm one of the lower linibH. and in th* end a large ab- 
Bceaa formed over the sacniin and the child died. The mother had no ro- 
turu of the erj-aipelaa aft<-r di^livtirj. 

This wiw not II ciuK of pu<Tpi>nU et^npelfts in the mothar, (or the dis- 
eaee hwl nut ouly preceded lubuiir but hml cnniplctely disappeared by 
the time the child was bom. It seema probable that tlie poimm was com- 
munirated by the mother to the infivnt tIiroit<;h the milk from her brensL 
At any mto, it is difficult to say in what other way the infant emdd have 
contracted the diwiiK*. 

Mfirfnd Aiuitomij.- In the skin tho inflamed mrfucc is red, hard, and 
brawny, with a well-tlefined margin. The ittluesa dinaiippais on pnwsure, 
and the hanlnesa in due to an-t-umulation of senim, lymph, nn>l roi-pii»olre 
in the substance of the <rMUh and tissue beuealh it. U ILo u'doum bo ro- 
piuuM. tht- pnii is dull red in culuui-, »ufL to Ihu touch, and ]}itH on premnre. 
Tlie men uf iuHanmialiun rapidly I'xteiidii to uei^^hbuuriu^ parts, and as it 
Bpreads the skin tiret attacked Vecomes lesa ten^c and browner in colour. 
Bomctimes the skin alTection di^ppeant from oue part of tlie body luid 
reapt)eHr« on another without K[>rea(1ing along the surface. Tlius, it mny 
attflrk one limb, Uu-n fade in ita hrtit situation and bresk out ou tlie oor> 
rvsponding limb nf llie oppoaite half of flte body. 

^Vh a result nf the inttamnintioii, alMretweH may form in the subcutaue- 
ottR tiEWun ; And 8omeliiiio8 nlon^'liititj; may fx'ciir in the Hkiu or areolar tis- 
sue. Often vcsielc4 or buUa> furiu od tho inHniiiixl Rurfiwe, ospeciaUy in 
the severe ciuteH where there is fnibcutanenus Hloucliiug. 

In most injrtaneeKof erVHijtelasi in the infant, adjacent [sirtstdinre in the 
inflammation of tho akin. I'eritoriitid is oommon, even when the dermntitifl 
doctt not uceiipy the nbdoiainal pnri<.-te& Tlierv may ImiiUbo iuiUuimiation 
of other HerouK membnuie)! — the ])Ie<ui-a. the ptrit'nrdium, >md the eerebi'nl 
meuiii^ea Sometimes the ititLimmatinii spreads from the aldu to other 
pai-t8 by direct coutiuuity. Thus, it nia,t' pnwi into the ear by the au<Iitf)ry 
nieatUH. into the notte and thrual. by the utoutli. utirett, and laohiymal ducts. 
Ill otliar cases, the disease he^us in Ullage deejwr parts and eiteuda to the- 
akin by the same chanoela. In addition to the abore morbid appearanoeoJ 
oridence nf phlebitis, pneumonia, and onteritiN ia often olMKTved. liitcly^ 
micrnrocci, amiugerl in cluslern, have Ijeen diM'OTer*d by Fehleison iu the 
lymphatie vnsHola of tlie affoctwl portioua of Hip nfcm. This nbeorver baa 
ereu succeeded in artificially cultivatint^ tlie or^fsnismfi on polatine, SLod in 
till- course of tKo months reai-ed fourlt^n penerations of mirrocoiMii. Roma 
uf these cultivated micro^r^'anit<mii he inoculated into imimaU and others 


ititn the hunum Hubjt'cl In nlmoHi all coftest «. typical erj'iiipoUit foUowet] 
t)iP np^rolinn in the [^'twill or auiinAl expnrinncntcxl upon. 

.Syrn;.Jvm«. — The lUscfise pn-MUtM lUficrunt cbamctere accordioe to 
wbetber it orimM on a coiui«qu«uce of paer[]pr»l infectum or U iutluced by 
other cauties. 

Is the timt case tite general Byniptoms ue UiiuiUly violent from tho 
Rnt A ]Kitoli of bright reihif88 Hiiptvint uti wjrtir p;irl, of Uii> bLlIoiue'Ii. 
usunlty about the pubt-M. Tlii> |mu'I lixikH suuiewhiit sw(jUeo, tecin iinnl 
ami hmwny, and ha« a wcU-'lpfiMcd loiirgin. Tlie patcJi may he of liiuitfil 
fktt-iit. but Uiere k hif;b fever, imil tlie iornnt loiiks ill. in n-»U(WH, cricti 
freiiiiftntly, ftn>l is evitieiitly in grwit jwiii. By tlw iit'xt day th« area of 
rrvdnem has beoomo widonecl ; tho f«ver ci>iitiiiueH; the fonbinelle is ile- 
■pneeed, aod tbo patient B]««ps httle aoil is v^rj- restlces aud fe«l>le. Tlie 
prvniiieliui rnntinneit to (>steii(l. It poflBee dowominU to th« lower llmhH 
mtid ii]>wardi( ovor ttifi tmnk ; the b«Uy iimially Im^ouios fuller ftud may lje 
tyiiip«niti{> ; Toinitiiif; &iid dinrrbtpa como on, and a jaundiced hue of the 
may bo obwrvc^I. After a fen- dnyM, ibe child falls into a state of 
and death may be pret«ded by (ytnviilHions and onmn. In this 
of tile diseiifu? Uie iliimtion ia HOtnetiaicw vriry abort. A £luld who 
B|)[>«Ara to be henlUiy and vi;,'on)uti when limt attacked rapidly fiUlu iulu a 
stnt^ of pi'Oiitt ratio u nnd may ilic tu a tevi dam TIr* illucBa may. howcfer, 
la«t for a loiiKPr lirue. The colour of tlio iuflaiueil sitrfiu-'e then lievouies 
d«^]>er and m<^re purpl«, buUffi appeaj- ou tlic mrfaee, u-bscMM-^ fonil in 
the iiiil>riiUintM»m tissue, or (;wigT«noii8 alouglis nmy destmy cuusidurabK- 
p~>rlii>nHi>f tlif Hkin. Infauttt attacked by the imerpenU form of i^rysipelii« 
art' uatuilly imkIci- two w«vlc8 old, and the itlnesg in iibnost iuvnriably 

When erTrTUpehw ornira as a result of other t-jtustes tliau puerperal in- 
fection Lbe early HjTiipt'xns nro le** violent. Tbo local affocliou Keu^mJly 
b(>gii« about the Renitnla, tlie pubc)*. tho anus, or the lower port of the 
aUIomeu. and Kprenda tliencc iu various dire<;tioiis. Wien il extends 
irid«]y, the pnrtu of the skin fint aflecttvl berome paler, but are liable at 
any time to a i«tum of the rednemi. Th(- clitM htw a pAlo pinehcd fooe, 
but may contitiuo to take hia fi>ud, oud his ili|?<»(tion is often turly piod. 
lo other cases, he n-futtea th» bottle or breaal. and nmy l>e troubled with 
freijiicnt tximitiu^; or lixtMuetta of (he bowels. The temperature is high, 
at iiisht it ri6€» to IDH" or 105", «iukiuB to 101^ or 102 iu tbv utoniiii}:. 

Comphcatioita often nceur in tliesc cilm-s. Abw«*sn<-!( may (onii in 
rarioua parts of the body: |^i<.n'i' m >um Kluuf^biug iiuiv nltiu-k the i;kiu ; 
pneumonia may or-cur ; or tlie intlimimntioQ may pasa (iircctly to the pori- 
toueuiu tlirou^h tlic recently IieAled unilulicus, or to the IBr^-nxand throiU. 
All infant under !<tx months old was brought to St. ^niomaK' Hospital and 
a<lmitl«K), un<Irr Mr. Croft, for on>fiipolii8 following TncMnntioti. When 
seen, tJie wliole <'cr%-icuJ ro^un imd part of the cheat were the Bt-iit of atlc- 
matoua trvHiptlaM. luid thero was great dymintRa without sjmptoms of 
cmiip. Tbe child was pU(;ed in a worm Imth and a done of ipecaeuanlui 
wide waa given to produce Tomiting. Xhoto mi-asures relieved the child 
for a time, Init in the evcuiug tbe dysimft-a returned with such inteuaity 
that tmclieotomy whs iwrformpd by tbe Surgical Registrar. After the op- 
mlinn tho infniit cnu><hed up HmaU piecea of curtilage —probably from tbo 
rings of the trachea. JSventunlly In- i-ecoTcretl. 

Whether tbe diamae he idi<i|Mihi« orariae froni traumatic causes ita 
grartty appenra to W tin- fmnw. In the tinit caae tho appearance of the 
fecial wymjAcTOB lb oft«u prece^led by aigiut of ctonagenicnt or alo^gioh- 



nt«a of tiie ilif^esttvc orpuia. In Mr. StniKuell'ft caflc, iK'fore rofcm-O to. 
nil iufant of ci^'lii ncekx iM iuvi Wan s fiiirlv lit'altliv iliild, hut for ten 
ilavH or so liih1 lx'«>ii postuui; very finu, [uik>, (mstv-lookJii-^ motioiiH. Tlie 
child woe tniddenly takcm mtb seTere ffrmptoms, nod TvheD first b^ett was 
lying wiU) hiH lii-iul thrown back and nin thumbs tvriHtml inwnntiH iijton 
his jialiiiK, hut tliere wan do r^lxactioD of ihe abdomeh or HtrabismiDt. 
Th<* pupils wcro oqiutl and ftctod to liKbt, tbo pnlxn mm npid, the tcmpi^r- 
ntiti-c woa normal. On csomiiiAfion aught oxltiua of the Hc&lp vns i)nt]4Y<d 
i)u tlie oucdpito] Imne, but tliern n-aa no redneoa On the hrxI ilajr tlwj 
(fdr'iiintAiiM jiort wns red. (>n tin* thin) dny tlie <"pivt>ral mTiiplpnw bad 
suljvidoil ; but tlio ur^'^ipolni) hutl tspixtul to tlic (orclicud luid down tite 
bin;li of tilt) uvck. AfttrwardM it oslfiidtil o^r tlic (uoo, amui, and trunl. 
A vt^tdcle tbe size of a lilbert and filled nitb clear Henim formed ort^r the 
l«ft elbow, and another appeiured a little later on tlie thigb. Aa the dis- 
ease advuioed. the ftVlonieu becnma di>ttonrl(!d and lympAuitic. and tho 
bi'^HtLiu'^ opprvniK^l. No miiu'hief viut diMt^uTHfed iu tlie clietrt. Tlie child 
Honk ami diod ou tlie tu^vt^nth dav. 

In tJiia c&ae the early cerebral symptoms (retraction of the lieai,! and 
tunxting in of the thumlis) were prolmbl.v fTi-niptouuitic of tbe i^eoeral dit>- 
Mse ud not of on^* q>»cisJ tutrn^miiinl complicauoii. They were of »bort 
dvimtion find quickly dimppf-nrcd wIx-q tho ^ikin affection l>ocuue marked. 
The t>-nii)aiiilcH and embiuTntsment of breivtlunK were, no doubt, due to tbe 
ocflurenre of peritonitis. I'l-eiiitiniloTj B**niptomH. inii--b an wei-e found in 
tbe lUwve iuHtanivt, are not common. Usuallr the tirst indiratioii of ill- 
heftlth is thu UMntrtV'Uvc of Lhu ciitaufous rv*liii^!(K and ttwoUiuf;. 

Ill tntumatic cawii the dunttiuu of the dist-use in oftt-n cou)ddenibl& 
The iUuesi may last two or tliree we«k», or e\-yu kmger. RocoTen- is not 
a fre<iiient terniination, wid usuaUj death ia brought aWut by one' of llio 
many complicatioutt to which these cases fu« lialilc. If none of these occur, 
the I'sae mav tind fa\-uuriibly. ev6n although tbe ery8i|HilAs has apreiid ex- 
tensiTely an^ involved the jjrofit#r pari of the surface of Ihe body. The 
subsidence of the cutaneous iiiUnjintiation is followed by deaqiuuuation of 
tlie epithelium in the portiniiH of skin afTeeted. 

Itiagnoi*i». — Tlie uaturo of Uio disease can Bcaroely be niiRApprehended. 
A [mtch on the skin of bright re«liicss. which feolt) brawnyto the touch and 
i» perhaps rpdematons, spreads rotitiniiouHly over the surface, and is boumled 
by a wc-il-detined mor^u — these local in'mptoms combined with the aevcre 
g^iiej-al difitin-bnnro and hi^b fever, moke the diagnosis of erysipehu an 
eaay niiiltcr. 

jPnyii'txiii. — ^Vhen er^'siiielas octruni iu an inf&ut of a week or fortnight 
old, OS a result of puer^ierai infection, the prof^otda is moat serious. Very 
few of these axactt rec-owr, nlUiouKh Trvuatieau has stated that iu cases 
wtiei'e abscewtM have fonued exteintireK, and in these c&mb only, he has 
kiiowu Life to be tuired. Coufie<)uentIy he iv^iiitlcd the occurrence of ab- 
Bcesses as by no means an unfavourable symptom. 

\S'lieu the disease ivisea aa a rcKult of other r-auses the child's proe> 
pecta ai« more hopefuL and are bi-i;;htor in jirnixirtion to his a|7e. his 
general strenf*t]i. and the heelthfiilnees' of hi» Hiirroiindin|^ Of forty- 
Uiree cases collected bv Dr. IjewHs Smith eighteen recovered ; hut of tlie 
cases of recovery iu only one was tJie child younger tlmo three montlis. 
If tho disease attack on tnfont durinfi; the tirat two or tliree weeba nfter 
birth, dentil is almost certain. After the n^e of six months the proportion 
of recoveries is greater than that of the deaths. 

In all oases uia ooourreDoe of a serious oomplioation greatly reduces tbo 


chOd'e Chanel's of eacape, and if peritonitia occur, we cim have little hope 
of a frtToiirnklfl issnie. 

TVwo/miwi/, — In 4-as(tR wherfi Uie diROABo n.ri«ts from pnorix-ral infectioD 
b«atineiit has been fouuil of little value. Alc-ohulic HtimulatinD ami 1b<> od* 
minifltratioD of ammDiua aud boi'k may be uwful iti supporting the 
Htr^ngth, but lora! tmstmeot of ereiy kind appcnrH to be luxilem. It 
^ould be adrimble iu tbese cases to mnko trial of beacoftto of aodor— it salt 
wliich tuw been hi;,'hl,v praisetl by Dr. Li'lmebach for ita vulun in puar- 
peral f«Ter in tbe adult. Two ur tbreo graiiis might be giveu to a child of a 
week old every foiur hours, and if tbe fev*r were very high, one or two grains 
of (luiuine mi^bt \h: aiMcil oni-« in the day to a dose of the bcuzuutu. 

In eases wuere no puerperal iufectioa n suspecleil. (be child shuidd he 
made to take Uie Ijneturo of j)©rtrLloride of iron iu (rociueut doeea For an 
infant of (Iiree niontha old fire dmpa uf the remecly may be giren iu g\y- 
ceriiie every four bniiri). At tJie same time llie strength dlould be sup- 
porter] by a cnrcfal diet. If tlie child bo at Uio breast, the mother's uiith 
is no doubt the best food be caq take. In addition, be ta&y havn a tea- 
spoonful of the brondy-aod-c^g' mixture two or three times a day if his 
footanelle is greatly depremeu. Aa long, however, as the strength coQtin- 
nes good there is no ncoeafobf for stimulation. If the patient l3e bn&d-fcd, 
oars sliuiild bo t&kcu that his mill, iet tlilutoci with barley-water or thiclioned 
with gelatine ; and ih^ atooU must bo iufipect«<I to nee that undigested 
curd ia not posHing away from the bowels. If tliis I>e so, the milk should 
be diluted witJi half its bulk of b&rky-water or aq. calciB ; aud should be 
aromatiaed by the mlditiou of two ten^pooiisful of an aromatie water to the 
bottle. Mvlliu'H food, white wiue whey, etc.. luav also be ^veru 

AVith regard to local treatment, innuiuorable applications have been 
recommended. Moiit of these are aeilativo or antiseptic. Thtiet, the in- 
flaiBed part loaj be anoint6<l with an ointment composed of equal parts 
of extiKCt of belladonna and glyeerinc, and oovei-rd wilh cotton wool. The 
application of oil of tiurpcntiuo has bcuu recommended by Hostreiter. 
CATBZiumi speaks biRhly of bruahing the surface with a lotiou composed of 
one part eneh of camphor and tannin to eight parts of etlier. Fainting 
inth tinoture of iodine i» advocated by some, and with a Hotntion of car- 
bolic acid by othi'm Hcppel statoB that the spread of Uiu iuflnnmiution 
may be limited by paiuting the skin at the circumference of the patch, and 
for a tinger'a breadtli on each side of it, with a ten per cent solution of 
carbolic acid. The brunh should b« umcJ ujitil a difitiiict ttt^Uniug of the 
iDt«^ameiit has been produccnl. Tliu ]itKii recommended by Huetcr. of in- 
jecting HubcuUuieuiiKly ai-ouud the mar^'iu of the pntt'h a tliroe per eeut 
solution of earbohc acid, ia inmlmisiiiblo in the case of ft young child, in 
wbom symptoms of cai'IxiHc wid pniHoning would he easily produced. En- 
dMVOn to limit the ^irciul of the ervKijielns, hv n linn drawn on tlie skin witJi 
nitrate of silver just beyond the miu^in <if tlie intlnnioil pntcli, have been 
loand to be useless. In the irhikl mirii a prot-evdtut; ie to be atrou^ly dep- 
recated, aa its empln\-ment Ima been sometimes known to lead to the for- 
Biation of troublosomo sores upon the aurface. 

An important dement in tlie treatment appeon to be isormng the in- 
flamed surface from the air. Recently, Sir. Borwell. reviving an old 
method, ha.i found tbe utmost benefit to result from covering the affitcted 
■na with a thick coating of common white lead bouae-paint, renewing the 
■BpUcatiun us ofleti lut any crack a]>]>eftnt on tlie surface of the paint. This 
pwD of treatment scorns not only to n-liew the pain (piickly, but also to 
ndaoe the temperature and hh\-u'urably iufluuuce the general HymptomB. 



WtioopnTo^oDmin, or portuaai^ is an infAcLious di&oKler in wliich catarrh of 
Uic air-|wuHn£»s is oniubin«(l witli nerroua EQrm[)toms whiob tnaT aaBume 
nnr snrious pniporttoiix. Tbo aflection occurs iu npidetntos nn^ may at- 
tark tbo rmiiigi>!tt iii()uit8 : iii«li>e«l, iionictJmeR it aj>jK«u« iranicliately alter 
btrtlt. ui mtch youu^ vbildrvn v]ioopiii^-couf;b, «Teu wbcu not of a tetwte 
tT)w, nuty owiac nrrioiiH i-tinsp^aencea. It is prJnri])aIlTi1aDgemiiB. liow- 
evrr, through its foinplieAtions. TtaeM are ounieroui^ and (rftoD a|ip«ar 
tonwda (bo cn<l (•( tlto <1i»c4it(«, vrbm the pationt's atrailgtli is reduced hj 
Um kngtli and at<Tcritr of his iUitoea 

OmhMoa.— nw dJacasQ uhurIIv occun in epidemica, anil appebn to be 
enuuontly mf«4.>tioiu. The duuiuel of infection is the breath and cxpecto- 
t»tk>a ; luid till- virus is capable of being conveyed by the almMphciic or 
•m by Um dot^ML CSiil^rBU of all ag«a are very ausceptiUe to thu infeo- 
Udus priacipls. Ttw di acau a is exoMaiv^- common nndftr twu years of 
as^. Tcry codkBUHkt •vm). during tb6 first twelve montha. Cnfortutmlely. 
i lur« kf])t BO systNiiatie rroonl of tbe inanv cases of whoopiag-oou-^b 
vUcb Inw passMt uudvr my iiotioi*. Imt in vighty-aina ana of which I 
have fKmemd ih>te« no tew than twunty-four oociirred in in&nts duhqg 
the fini y««rof life. Even this proportion probably represents imperfectly 
th* frwnwDcy of the diaeaae in youos b^iies : for in such snbjMta the 
1 — ( ime atsft* ia oflau abnut Dr. R J. Lee is of ofsitioB that infants 
•mr ttoM pNtoaois uoch nnsre bvqnsiitly than i« mpfcmi, a&d asserts 
that in a vary youag chiUI a whoop ouf^t rather to excite aurpri ae than to 
be hnksd vpm as aa uRlinarr avrnptom. This is, p^rh^ii^ an extreme 
~. wM thamiiDo iloabt that in iofiints the ^seasa frequently aa- 
Ihs lorai of an obatiaate pabiionary oatarrh with but UttJv Uiyni^eal 
SfMB. Alhcr Um fenrth ywar tbo ilisMie becnmea very an : but it may be 
wmtm at a»y time of liK evea. m ta well knowo, quite at tbe dose of es> 

Whae^iBir^oa^ aHOH to be men c o mmn a tn the ^viag and automn 
Ihia in Iha other Haoooa cl the year, and the ayaWwir is oflan ftxmd to 
■ncecle «r to feOvw qutekly upon aa epidsMJe el meadaL A patieot who 
haa paiaiJ thziw^ one atteck of whoopiafT^ov^ is la £Ufa daoger of bis 
dtoM* bautg lepsafead. far a sscood attach in tbe ane aafaiac* is lara. 
IW iaJMlMab howvnff. ktAi far a niastdsnble tine eftsr Oe whoM hae 
WM wl to he hg ar A Dr. Stimreisatopnuaalhalalbaat sxweehs Aoold 
heattowadtocAwae beiun the palianft oan be Irastad to associate with 


We tad MM «f 
wilh h j pw M aie<iott «l Ae 



of the air- 

wnoopiKthcoron — pathowmjt — STSTPTosta 

within the glottis, of the trachea, and of the bronchi and their ramifica- 
tions. We aleo find c«rtiun cons?qti«nc«s prodoopd by violence of cough 
Bud 8pa8iD, viz., pulmonar}* collapse and eniphyneiua. lu ftdiiitioD, we 
nsmllj' meet with some other morhitl rhnngfts due to the com]>hcutiDU ty 
means of which tho fntnl itwiie biui beon brought nhotit Thas, there may 
be seo-ioaa congestioD uid evtu oxtravaaatiou of blood into or upon the 
bniii. and sontetamee (dgns of thromboHiH nf the inlraci'aiiial Jitiniifies, 
■hown by colourlen dota of laniiiiftt<>d ntnieturo adlteiiag to the mdle. 
Hie longe may be the seat of cntarrliol piicuinonia, and oceaMooaHy email 
extravasAtionii are seen licrv as iu the bmia SIorooTcr, tfacro is almost in- 
VHiinbly OQlargement of the brunchiid glands, aiid the under Hurface of the 
tongue DUiy bo ulrerat^l murti or leae extensix'ely. 

No satisfactoiy expLuiatiou hoa yot been ^rco of the rvol uuturv of the 
fxnnplaiut That the diaeaee is due to inflammation of the pntfumoguHtrie 
nerve has been ehown tu be erroneous. Preasare apou the Baiue norre b^ 
enlarged f^landa may be rejected for the aame reanons vbich render tbia 
cxplnoatioii of tJie phenomena of Inn'ugismaii stridulus tut in.>H)t1Icient one. 
In some rospecta the affection rt^!8«iiiljle«i a Kviuotic di^ewe ; in olhora a 
ttewetxiM. bomo writers coimder th<? complniDt a purely catarrhal one ; 
olbetB lay most Hti-ee« ajmn the nerroiis symptoms. Tliat the diaeaae is 
•omeilung more tliaii n m(>re catarrh \» shown by the infectiooH nature of 
tbo secretion Uirown off by tho miicons membrane. In 1870 Tjetzerich 
believed bo bad diecovvrod a epecios of fuu^a in tho sputum, and sup- 
posed that this was the morbid material which, carried fmu] one person to 
another, settle*) upoii. the mucous memlmuie of lbs air-pawagea, and by 
its irritation garo riae to the apasmodie ftympt^ua. Otber obserrera^ 
howrvv^T. have nut confirmed tluB ollt^^cd discovery. More lately I>r. 
Carl B'-u-^vr. of Bucu. hits described a bfunlluit which be baa found iu the 
tion of chililren suflbriug from whooping-cough, and fitatea that 
to thia complaint, 
{iteiu'otic character of iiertnasis in Bhown not only by the laryngeal 
it by tlio nolent agitntion into which tlio child is thrown during 
a paroxysm. When ho fools tho dcaore to cough beoOBoiog irretistible h» 
clutches at ilia mother's drom or the noorest object capable of giving sup- 
port, and bia whole body is agitated by a convulsive trenibting. This agi- 
iRliaa ia tuiually nttributed to terror, but it i.i morn probably the conae- 
({nenco of a guocml uurvoiiK cuiimiutiou which, ciuriixl to a higher pitch, 
nwy become a gcnuiao cuuvulsivu seizure. Adlalin^^Bhudjihyiucinu who 
wsa attacked by wliooping-cuugh after middle life, tn descmuitg the uer- 
fOOB Agitation induced by the spuam, aeeured me tluit in tlie paroxyam he 
required alt hLi 8i:<lf-control to arotd beatiug with Lis {vet upon the floor. 
It seems, tbemfori', Uint tliu neurotic elotueut of the disenHe in sometliiug 
more than n mere nervous apaam of tho larynx and diaphragm. Tlicre 
apiiears to be a general agitation of the whole nervouH eyatem, which msy 
be more or lew pronountwd according to the severity of the attack ana 
the inherent sascoptibility of tbo chiliL 

Sympiona. — The incubation period of portusais is difficult to aacortAin 
on soooont of tlia uncortaintr as to the exocL day upon which tho diaeaee 
csa be said to begin. It has beon estimated at from two to seven days. 
Other obserrent ore of opinion that it inny last a fortnight 

When the dis<.iLHc l^cgins wc fiud ttiu symptoms of catarrh of the air- 
psssagea. The eyes nre HlighLlr injected, there ia BDoAling and increased 
Hi'liiU'iii from the nose, and the cluld miou begisa to cough. Tliere ia 
10 temperature usually rising to 100°, and the pufw ** 




quickened. In a tiny or tiro there may b« ui aililltion mme iDcnaaed 
rapidity of breatliing.* If tbo cstarrli offMt the gastri<- }U(i(«u8iD«mbnoQ, 
there ia loss oCeopetiU! and the rliiUl tuav be languid and niopo. Tlia 
syniptcnDS FCKintMe tliO!t« of nti onltiuirr catarrh, Iiut tlteir iipeojfic charao 
tor uiay tin KoniPlimra detected "bj nntiriDg the nnnrnml obsttiuuj of th» 
cough. It is rcp«fltc<l at voiy short ii)t«rTa1s and somfttiiDM it amiost io- 
oefisant Tbm catarrhal atatfe lasts (or a vimablo tdni& It may occapy 
only a fen ilnyn or may be continued for seTeral weeks. The symptoms 
nmially increase in M-vority aa the daya go by. I'be cough becomes more 
troublcimmt', aud i» vorav at night than in tlie day. If the child is old 
enough he coniplnina of a harawung ticklinff in the throat : and thiin* is 
often violent sneezing, with the ejection of much ropy muoUB from the 

Afutr A time a diange in the cliararter of the cough obown that the 
spiisuiodic stage baa be^ruu. The n^u|:ch oconra in parox^i-nns, and has 
Bach a dietinetiT© cliaract^r that it nt onw bftmyn Oio untiirf of tlie child's 
complaint. It contunta in a number of nhort bnckii, foUuvrin^ ho i-nnidly 
upon one another as to allow of no iiufpirntory effort Aa ihcse continue, 
the child's face tumfi from red to pur]>lc, and seems to swell and (Lurken 
at the same time. At K-ugth, when the lungs are almost exhausted of 
their air, and the pnticot nccnis ujjon Ihe vcrj- point of auffocation. air is 
at last diBwn in with a long, dt^^p inxplratiuu, accotujvuiied by the chanuv- 
teristio " Idnk " or whoop. Immedia-tely, howerer, the cough be^fins agoiii ; 
and in this way the long rapid expiratory cough, the eigna of imminent 
asphyziB. and the slower wnoopiuti inspiration atux be repeated aeverat 
times before the expulsion of a lai-c« fi\iautity of thick tenacious phlegm 
from the mouth, and perhaps the ejection of food mixed viith ropy nmcn» 
from the stomach, anuoiincen the end nf the attack. Tlie rliilii, then, if 
an infant, sinka ba^i: eshaiiBted and ]>erHpiring in liia mother's anna, and 
if the (lough do not n:;tnm immediately, iisuiiUy falls into * heavy deep. 
An older child sctms ii UtUo lunjnud. but if Uie iMirosysm has not. been 
severe, may return quickly to hia aiuusemenL if. on the contrary, the 
BpBBm haa been pnitonged, he may seem dull and confused for a time, and 
may complain of heailaulie. 

During; tlie ru» of couching tlio pulse becomes rerv rapid, and is almost 
uuoouiitable. If w£> hsten to the back at thia time we near some alight 
wheezing in the lar^c air-tubes during the expiratory conab ; but duiin^ 
the long-dnivm iusjiiration any filiglit TeHicuIar sound which might be 
heard U covered by the noise of flie vhnop. In Ute intervals of the coocfa 
nmuniltation in an uncomplicated caMo mrrely rercAls a few livge bnbbwB 
mixed up with dry wheeziDg sounds scattered about the lunga 

When the paroxysms are violent they arc a cause of greet diatress to 
the patient. This is wdl shown by the elforts a young child will make lo 
keep them back. He may be noticed, while on his mother 'a lap. to hold hia 
breath and sit perfectly etill in the hope of repr<«8ing the cough. When 
be feels that the impu^ is getting beyond his Lvmtrul his face becomes 
oocgested, his brows contnct, and sn'^iil breaks out on his forehead ; and 
as the coQTulsiTe expiratory rlTorts Wgiu. lie rlutchea at lits molbcr's dress 
and often tremWea all over with nervous agitation. During the paroxysm 
the straiuiiig m&JF produce rupture in a chiM prediH^iONed to hernia ; *and 
biomorrhftge from the intense congeirtion induced is a common symptom. 
The bleeding may take jikce from the eyes, the ears, the nose, the luoiiLh. 
and sometimes from the lungx. Cracks about the lips and sore places on 
the gums almost always bleed daring the fits of coughing. Bpistaxis is 



Tery wiramon, Wben hnpmorrhBfifft owrurs from tho noan the blood does 
oat al\rayii flow forwimta thi-oti(;li tbc nnstrilM ; otieu it puinwa bnckwimls 
throngb tbe posterior uiu-eH into Uie tlirout. It msy be tbfln Bvallowed 
nnd (lificliarged aa bkc-h mutter b; hIoo), or be vomtted after the next at- 
tack of oougb luitl cause ^reat akria. In other caa«s tbc blood irritutes 
tbe glottic itiul iuduneii a frenb |Mrox>'8iu. It a tlien expelled witli tbe 
oou|fh and is supfxwecl to innio from the luiigH. 

Th« number of poroxvsuis that occur iu the twentv-four hours raries 
very much acconling to the severitj of tlie ntlarli, aikI [tarlly, too, nrcord- 
ing to tbe namber of disturbing causes to whicb tb« cliiM ix expoee<]. la 
Mv«M eum, wbAre th« dightmt omotioiin] or otlior iiitiucncB will induce 
ma attack, tho iiumbt^r mii>y be conBidernbly diminished by quiet and judi- 
cdoos amusenieiiL Tlie cliild often coughs more in thn night than during 
the (lay, for tbe oocun'oncn of tbe fl<>izureH nppoant to bo favoun^d !>}' tho 
recumbent poaltiou. Botwvco tho ])arozysuiH, whou tho apustn us viotont, 
the cluM's face may rt-niniii permanently congested. The eyea are red 
wid often bloodabot ; tbe eyelids are heavy and HtvoUen ; tbe face and lipe 
are dull red ; there is r dusky tint romi<l the mouth and uuder the eyea, 
and till' vciti8 of the ueck are full. 

Tliif attacks thom8«lTe« vary in chanu?t«r. The whoop may be entirely 
absent throughout the diHcntie. TIuh is siiid to be common iu verv young 
iafants. The number of exiHratory effortn in very variable. Usually there 
are only two or thre«, but they may be much lunre numerons. As a rule 
the coughing Sts arc longer at tlie beginning of tbe spasmodic stngo, when 
BWretioa is thinnoraad leaa copious, tliau at a Inter period, when it becomes 
■bandant and more tenadoua After tlie vrhnop hiia loHted a fortnight it 
growB lesa violent and is lesa frequently heanl. It only oocura with the 
more violent tita of coughing, and in the mikler oneH the breath is drawn 
more cfuietly and wLtli gmatcr taxc. At tbc cud of three weeks ur a month 
it becomes very nrc. luid the cumpliuut may tbeu be aaid to bare paiwed 
into the utage uf decline. 

The M-hole time occupied by an attack of whooping-eongli varieB from 
a fortui;,'bt or ereu \tm tn two mouths or longer. Tbe duration is often 
difficult to lucerlaiu, fi>r nft«r the Kpfwmodic cough ba« <1iKap]K<ared and 
tbe diHeose bas again come to ASKunio an ordinary catarrhal type, trifling 
, aocideDts, Kuch as a chill or an error in diet, may aet up more nt^re e^'mp< 
' toma, and the whoop may even return for a tim*. In this way the com- 
plaint may be prolongcil for nmny u'(>ota. 

Compliroiioits, — There urc certain accldcutjt attendant upon tho <;om- 

Elaint which may be ii cniiHO of dintrRsa or danger to tlio pflticnt. Sub- 
nguU ulceration in common ; biemorrhage may be copious ; the vomiting 
may greatly intei-fere with nutrition ; bowel complainta may fiupei^ene ; 
the Dervous symptoms maybe cxagf^cratcd; ami various pulnionary di»> 
eaiiMinayeusue and, if they do not prove fatal iu juriomdy ^ect the future 
welfaire of the child. 

The subtinyual nlctirafiott baa been before referred to. It occupieo the 
nuui of tbe tongue and may extend for some distance on each side of 
' Diiddle line. Tbe sui-e may vary from a mere abrasion to a deep &»- 
~MU<e nith a gray <x yellowish sur&toe. It ia only seen in cases when) the 
child has cut the lower incisors, and ia tlie direct coasequence of tlie »cTap- 
ing of these teeth against tlie imder 8urfac« of tbc tongue an thi» organ ui 
ptotraded and witlidmvn daring the paroxTsms of cough. Hlorxl nftpn 
exodcs from the ivbriuded surface towards the end of a |Hiros>-Kiu, llie 
is not a conatimt Hymptom. It never appean before tbe 


siape, l)ut may then bo »pn an early m the fourth (Uj of t.he whoop. Iti 
im inoRt comtDon in infanta -who have cut the tvto r«ntnil lowta- uicisors luid] 
no other t««th. In diUdren who have cut all their t<eth the Rymptora is^ 
much tosH coiumon. 

Bamvrrhagt! must cot be loo)c«l upon at in every case an tintowanlj 
accident Wlien the Bpasm is riulont iiml th» conpCKtion of the b«ad imd | 
Ekoe extreme, Uie rehef afTorclml by a dischar^teof bltHxl fixjoi thcdiirt«nJcd 
vesseU of the nose in no douht nftfii a salutan- inckleut. If. btnrerer, the 
hirmorThaj]^ oeeur froqucntly a.iiil he very copiinia, great weakneM may be 
oeeaaioiud ; imil if Uio child' bo already redu<M!<l by the violence of tlie a^, 
tadcB and the di>dcioncy of nouriabmi-iit ocfamoned by repeait-d %x>mt1Jo2'( 
the kwB of bloml may be an BcldiliuuiU reanou for anxiety. Rupture 
TBBaels elaen-hore than in the noee ec-ldom odours to any e\teut. Bio 
cjfi-ted fn>m (lie ruuuth daring whooping-cough ooioes almoet iiiYitrmhly 
from this Kource. H:i-niouty»iM in rarrly seen, for bVKMl coming up from 
the luugH after au attju'k is uKiially ttwallowe'l by children, and ia aehloni, 
if ever, sufficieuUy coiisidei-able to he a source of dan|*er. 

II.rmonliAce may alno fxxnir into the suIk-u tan ecus c^Hinective tiama of 
the eyelidfl anil that beneath tha conjiinctiiii. The eyes are often b1nod> 
filiot from RmAll «odipD(Woei and oecaHionnlly wo aee' little extmTasntiona 
in t)io tbickviicd eyebda. 

Hiemurrha^ ^m tho earn la the amaeqaence of mptore of the trm* 
panic yieiubrane. Sewral iustuncea of this arrideul havta been recorded. , 
It i« oi>caHioned bv the blu^t of air which is forc«d llirougb the Buatachiaa^ 
tube during the titn of ooughiiig, and a certain amiiuni of bIoo<I exudes' 
from the lorn RurTarv. 1u two out of four caam inib1tKlit-<l by Dr. Gibb 
the rupture occurred in both ears. 

lu v<:ry rare va»ta lucmorriiaf^ boB been noticed in the btain and its 
membraoea, causitig death. 

Certain digt'iaive troubles may niisa Vomiting at the end of a fit of 
eouj^hing is a familiar symptom. Cmally it is of lilUc couHciiucncc. If^ 
however, IJie nttucl^s of mu<;h onrur Tciy frequently, and arc followed in 
each CAM^ by sirkness, the child's oatritioD is visibly nffpcted : for atmoatlj 
all the foiid taken is vomited before there ia time for digeation to begin. 
Etui if vomiting lh not exceamre, tiiere iit off«u oouaiderable tnterfertruoe 
with nutrition, for the ratarrhal condition of thegnatric muooua Diembraoa, 
ia ill adapted to further healthy digestion. In many cases, no doubt, tbs^' 
tough muciu which eoftta the wall of the atomach prevents the food from 
being properly minsled with.tlie digvative juices, It is not uweommon. as 
M. Killiet lonj;; ago pointed out. fw foo«l lo bo vomited Httle changed »ot- 
erol hours after a meal On O'^connt of the mucous flux in the liowela 
worma ai"o a frequent eomplicatitm, and diarrbrna is esiaily excite<I. A cer- 
tain nmnuut iif looaeuem of the liowelsia preneitt in a large nmjority of tlie 
oaaea of peituatis, and considerable quantitiea of macua arc paeaed in tho 

Ntrvout accidenta form a vcrr important class of complicationii. Somi 
tdmea the laryngeal s|iaam is exaggerated. It ia not uneommon to aee 
ehiltl at the end of the long expiratoy cough, instead of at ouc4 begin nin g 
to whoop. rem«in for some aeconds with darkened face. atariuK 0}-es. an3 
open nioiilli, making a^ntated movementa and rainly atriving to orerconia \ 
the s)maiiioili(T contraction which ia eloaing the entnuice to bia lunga If 
prolonged tlie n>rbiiu a^UU greatly to the gravity of the caae, and may even 
aet(ttuiino the fatal iwuc. This is ♦wpwi.-dl y likely lo li«pi>en if the i>er« 
iiuaaia ia complicated with aerioua lung nuscliief. In a aibu which cama] 

wnoopiNo-cocon — cohplioatioits. 


under my own notic* — n child of aertn years of age, both of whose lunga 
vrere Uie seat of rntairhal pneiimonia — iJie HpanitiH were vei^" Tiolent and 
prolongpd, and in one of them the jintient liird In n cdso wcorded l)y 
Dra. McjgB and Popper, wliooiiing-ootijfh complicntcd a case of larjiiP'aQiiia 
Ittridulutt, aad the child diod in n Hpiuan. K<>iRf>titiieii tlie patient fiil]8 into 
a HtjUc of sjmoope from wluch lie cod be roused only with the greatest 

Ihe Bemi-a8pbysiAt«d state in which the pntiont is often loft after s 
seTere paroiysui of cough may he a couse of general convuhaons. Ednmp- 
tie atliKtkn, indood, often complicate pertuHsia : hut ultUough their oecur- 
reut^e ehould give rise to great anxiety, tlic aeimires are uot ncctfRsarilr 
fatal. U the conTiilsion be the couttequcuec merely of <leticieut aeration of 
Uw hlood, the return of freo rMipii-ation reiuOTen the chinger for a time : 
bat if the same ooadition be fretpiently renewed, the child's state ia a wit 
anxious on& So, alsa, pouvuUiouH excited by enilioliHiiiH or oongefltiona i^ 
thfi cerpbral \-essel.s, throiiilio)<i8 of the craninl nnuses, or dil7iise<1 mllnpae 
of the lungii, arn vci^' sorioue. Thr-we Rcnernlly mreiir late in the rlitteam 
Wd »r» almost ioTjinably fatal. There ai-e two forms of eclftiaiisifi linblc to 
happen which are less dkngBroue. One of these in due to an oxnggrration 
of the nerrouH excitement which !$« an ordinary Hymptom. of the dtHenae. 
Is highly Henaitive children it ia probably not nnconimon for eonvulaiooii 
(o take place from thia cause, especially if the rtti'cu^th hiut been ^piickly 
reduced bir copious epistniis. So. also, the onset of im iuflarainatorj- com- 
plicMioa la often in<hi'ated by a ironvnlBive (it, and these attaclja, luce the 
m«ceding, are often recovered froiu. It, however, a convulsive tit occur 
lat^ in the disease, when there i» much coDHohJatioa of hing, the child 
aeldom rocovcn. In oooueotion nntli tliis subject it is well tu reuieriilier 
that convulsions oconrring in the course of 'whooping-cotigh may h& dito 
only indirectly to that, disense. Tlie tendency to eclamptic sttAcba winch 
ta common in early life ia, uo doubt. hoiylil*ned by the state of ner- 
vons excitement in which the in'Kteni in maintained by the tUii*«a. At any 
tale it ia oonunon. CHpociollv in rickety children, to find con\-ulsiona hu- 
peniene in the course of whooping-cough upon rerj- alight gaatric or in- 
testinal nritatian. Convnlaiontt oceiirnng in pertusata without being 
followed by ill comsequcucets may he. uo doubt, often attributed to this 

ABotber important group of oomplications conaata of the pulmonary 
leaiotiB which may occur in the coarse of whoopiag-cough. Theee. on ac- 
eount of thf native of the complaint and the tender a^e of the mtient, are 
jeadily excited, and often bnn<; the itlnesa mpidly bo a close. In fact^ the 
liahility to these accidenia couslitutea iu most cases tbs chief danger of the 

Collapse of the lung is one of the commoneat and moat fotol of thetie 
eompUi»tianit In n aavoro ct>at> of whooping-mngh in a young child thin 
aeeiileat may hapjKiB at any time. Indcf^d, it may be said tlutt at the end 
of trvry vidlont paroryam of mushing the patient ia thrcntuncil wilh col- 
lapse of the lung, for all the conditions whirh conduce to this diitfiater are 
present together. Tliua the fmaamodie cough almost empties the lungs of 
air ; the ropy mucua in the titiwHofferH an obstorle to its re-entrance ; and 
th« state of exhaustion in which the patient is Itft weakens the force of the 
Inspiratoiy act Tlie meehiuiiRm of coUapae of the lung aud the mymptoma 
ana eigne which rettult from it are deecribed at length in another place. 
It win besuflicieiit here to remark that the occurrence of collapse is often 
iDtUcat«d by an uttuck of ooHTulBkliui, ami if the area of lung aflRected ^~ 

22 > 


Ui'<;'', Ktiflddi (Iftfilh may eron enxue. Id Qu^ Imb sarious caam the chQd lie 
btt<-k witli JiiH li«nd low ; lug fore U pule or KligiiUy tiviil and eavsred witbl 
a cold Kwoat ; thu tyL-UtU iiud lipn arc dull rtd or [turplc : the Daren act, ' 
and tlie respinilioiis are fn-quciit aud sliallow. TIhtp is no (fi'tr; often 
ilie teiuponiture in lowt*r ttuui tialunU. Un t-samination of Uie ehefit we 
find a little dulneas nt one or botli Uisea behind ; Ote brrathing^ id hron- 
ctiiiU, iiud Nometiines Ioom emcUtag rlioocbus niav b« licard at Uic lower 
pai-t of cacli lung. The whooi) gOTHfrally oonaea when coDapM occuni, but 
the tita of coughing continue, nltlK)u<;b in & modified form, ociU add greatly to 
the cxiiaustiuD of the pati«at These cei»es aluioet iuvariabl; end in death* 
The child licH (jui*itly, an U unnilHiig to tilir a niuarle. He takee food withi 
difficulty and tteems afraid to swallow. If Uft(>d up Kiiddoul}' be may die 
from B^-Ill■ope : oft«n the end is prooeded by a coQvukion. 

Kronobitis and cntaiTli-il pneumnninare other cotaakonconaequfncefiot, 
whooping-cough. The ]>uluionnry raitarrh, which in oDa of the cbarademtio . 
featurea of the diwAAo, isr-fuilr n{{(;ravat4xl, lunl roadily invadAB tlM naalkr j 
tuliefl of ihe lung. In a young child, tocj, a broncbitia aoldom rcmaiua K' 
bronchitis, but the inilammation quickly travelii to the fine bronchioles and 
nir vesiolf!*. ThiiR a catarrhal pneumonia is 4>flstly aet op. In a wvere 
oitsu of jx^rtuiwlH the breathing h««ouii?3 tiiore tuid more oppressed aud the 
fiu-c niorv and more livid ua Lufe vutun'hal iuilamniut ion cxIi-ikIb il»i-U: but 
wh»n the tcnuinnl tubea are reached and cntairbal pDeumonia bc-gina. the 
change is at once announced by new flymptoms. The whoop ceasea ; the 
t«ui|)craturf ri^cati.) 102" or 103 ; tlie breathing ia quiclceued and Lkboured, 
and thv pulMe-rMpu-iition ratio in perrortcd ; the laos in livid ; the naree ar« \ 
widely uxpanded. Although lher<< may be no pennisirion dulness '^ phy8ieal<| 
exammatioD of the chest reveals Aome of th« lugns connected with tliis dan- 
gerous condition. Somettniea a tit of cQn%'ul.sioiia u»hen> in the compli ration. 
If the pneumonia Ijo estfinsivo the child gcn^trally diott. If it b« niodenu^ 
and the attack of whooping-cougb be nt-arin;,' its dost, he may rcwwer,.] 
but his life may be wiid tn hniig on a thread, for the occurrence uf a littla j 
collapse. Ktill furtlicr nHluciiig the amount of breathing upace left to him, 
may at once diit^riiiiiic tlie fatal isNue. 

Kiuphysciun of the lung, wlitch often occunt. ia a eomplicntion of Utile 
cravil 1, . It UHually occupies the uiijwr lobes and anterior borders of tha^ 
lungs It in produced niechanirally by forcible distenlioii of llie air-veai- 
cleA, air Ueitig driven from tlie lower paits of tlie lungs into the upper por- 
t-ions during the spuamudic cough, or rnthtr during the violent contrac- 
tions of the diiipUragui which immediately preclude the cotigh when the 
glottis is closed. lu the severer cnsee there ia some dilatation of the 
amaller bmnchi as well aa of the air<ells. The condition ia an acute one, 
and uaually subsidus wtien the diaeaae mswa ott In scrofuloua i^ildien, 
however, it way remain as a permanent le^on. 

Of thtise ooupltcations emphysema is one of early occurrence. Col- 
Upsw and catarrhal pneumonia occur late in the diseaae, as a rule, when 
the chilli's ulrcugth i» reduced and liie nutrition impaired. 

Bcaidea the above accidenta othora may occur. Laiysgitia is seen 
Bomotimea, but if not nerere adds Ufctle or notlung to the danger uf the 
caae. Pleurisy and jiericarditia are occasionally found, bat these do not, 
like the preceding, follow unturally from the complaint, and arc not often 
mot with. 

i^f^Ki'/fP. — When the disense has paased off oonaequenoefl, local and 
eoustitutiouid, nvny bo Inft behind. Any dialhMic tnint, previously dor- 
mant, is often rouB«>l iutouclirity. Scrofulous children may hecoiueimbject 


elironi'! diliobArgfM, inl^animntioilfl, ftnd otbor nif^n oi thnt (?onRtitiitioniil 
coaiUtion ; Bj-pliilis iu babies maj firet monifflst ilself dimDg or nitfr tui 
attadc of wbtiopiitg-i^ough ; and acute luberculoBU iv a not uufr^cjueot 
soquel to tUe (iisc-iu>e. Maasles and pei'tuHsis aeem to have n certain 
affinity iu tliat tbey botb protluoo aa especiaUy iujurioiut eOvcl upon 
acrofiiloDB chiUlrcD. In aucrli subjecta cbiucic coMotu eolui'gcmeiits of 
tbe oervical and broncbinl glaufU are common : rntorrliHl inflammation of 
the luDgs tuiiila to \)nm into a i-lironic stago uid pi-oduce serious miaobief^ 
aud chronic bi-oiicbitis witJi uiuphpifma naj nuke the child u pcnnanent 
invalid. Aoute tuberculosis, n*hi>ii not the ooneequenee of faereditaiy 
diathetic teodeno/ excited by the occurrence of wboopiug-coagh, may 
be set up ao n result of softening of OLBt-ouii bronchial gluuila, and tliis 
at a coD8id«nble int«n,-al of time after Ibe primary dispute biui come to 
rjui end. 

Bendas these ooQHtitutiou&l conditions tbere are other local oouae- 
I quoiOM of whooping-cnugh which it U iniportuut to Ijc- iiwiiro of. 

Jjarynpaatas striJidus is w>n]ctitn«8 a relic of the disease, tlie spagm 
persi$tiQ^ althougfa the other fijrniptome have cea«ed. Tbia is Dot com- 
mon, nnd probablv onlj occutB In tlie Hubjecta of rickela. 

Children wlioliare latclr pnnsed through an attack of vrhooping-cougb 
•re often alow to recover 'their 8treni?th and bonlthy AppearoQCe, even 
altluHigh iboy are innocent of any diathetic taint, and liavo no chcttt af- 
f»ction to Met up pyrexia and be a (nuse of weolcnesa. A group of Hjmp- 
loms is often noticed in mich tmbjectH which I have elaewhere deucribod 
under the name of " luucoutt diseoKv,"' and wtiich indicates a toarked 
iegne of imiiatruieut of uutritiou. The child is luii^d and pnle, or has 
S wlgy sallow uomploxiua ; he loses tieiih, in easily tired, and sleejM btully 
at ni«it Tbere ia often some diacoloiu-utiou under the eyes, aud th« 
complexion may turn suddenly jj^haslly white, as if tlie child were coing to 
binU Often he does faint ; and hi.* frequently oompliuunt of a Ktitch in tlie 
nde awl iamibject to flatulent pains About the belly. Tlio tongue pre- 
•eats a pocidiar appearance. It ba» a ^loftey »liniv look, ia often coated 
with a thin gray fiu*, and tli« large papiltje at tfie sides, although not 
prominent, are unusually di«tiiict. A curioua irritability ia n oiiaracteiiatia 
feature of the disorder. The cbUd is capricious uud fretful, and often 
oriea without cauae. Uo quarrels needlessly n-ith his brothcra and sisturs, 
and ifl some limes quite a torment in the nimier^'. At night be dreams and 
oftaa imkea up in violent panic- The " night terrore " of children usa- 
■l]y oocnir in Uie subji'cttf of this derangement, luid somutiitiui the child 
gns oat of bed and wanders about in his sleep. These spnptoins liavo no 
regular progreaaion. They are hotter and worse. Sometimes tlie child 
aeem« almost w(>ll ; tlien, in a day or two, he is as bad oa ever. The 
pnttentM ant subject to what are called " bilious attacks. " They are aeized 
suddenly with vomiting and purging, which lasts for twcuty-foni hours or 
a <Iay or two, and nt these times get rid of largo quantities of thick muctia 
both from the atomanh and Itowels. .^fter this relief they seem better for 
a time. They are lo^ irritable and languid, their t«inpcr improrea, and 
tbeir rest at night ts no longer disturbed. After a few dnya, however, the 
■ymptoms return, and continue until they ore again rolioved in tbe same 
way. Aa a rule, the bowels are nther costive, and an aperient nln-uys 
faf^n away much macus with tlie stools. 

uwee symptoms are due to a coutiuuanoo of tbo mucous Hux from tbo 

< Sm Th« Wutiug tHMues <if aiildnm, -fth wL 

fltiQientAiy eiiiiftl vihict is «lwiiyB nnsBitt to ii gronter or lem degTM in 
casen of pGrtuBsiK "niis copious *^ *"*■"* storalaon ute M ft fenacnt and 
CKUseH an Hcid clinni:;o in the more fcrmimtoble artidefl of footl. Tho ociil 
tbuN (reiicratMl pnrliiUlv cangiilAt«B the oatMnia, mo tliat thin foraiK a thick 
cofttiii^ round the interior of tbe iligeativo tube, lund nlw> covers Uie 
tniutscti of fuoil eMmlloived. Coottcciuviitly n proper a«linixturu of food with 
tho gwitric juicM nud other cUg:»stivB 6nidtt is ioterfered with, fligoalion i« 
Hlon- ftiid imperfect, and of tbe fo<>il which is tligested only n amidl pmrt t« 
broQgbt uitu i-otitact with tbe Abvorbont Tc«i*el8. 'Hii' diild roDMLxiuenUj 
g«t« tbtnnor und jinlpr. Ht- n udciikv oii account of flntuleiit [miuH from 
gasee diseogsged in the proceoa of femieutatiou, imd irrilablt uij acniunt 
of tbe excesn of ftcid with which th« e>-et«iD is charged. In bud casm th» 
etnticiatioii mny he very greni, and a^tbougb tbe nppe<tt« mnj be ha^, 
tb« food taken se^nis to be. niid often acttially ih. ui'iirly ui«Ii>hi4 for pur- 
poees of natritjon. CommonlT, bowoTor, wbrn iht- d^rao^tn^nt is serere 
tbe ajijielite fails, and preat difficulty ia fouud in pfi-su-'ulinR thi; child to 
toko any iioiiriRhmpnt at all. Pai'asitio worms, which finil in the alkaline 
tnurtis n eon^uinl iiiihis for dcvi'lnpmi'nt, freimently (vimplicaU- tliti^ de- 
raof oment, but it is to the di^fc&tivc disorder aou Dot to thu >\'OiTtu that tbo 
aymptoms are really due. 

Ihngvnnn. — It in often reiy difficntt to usy whetber or not a diild has 
eot whooping-Kiugh. At tlie beginning of the cnlarrhnl stage a diagnoeu 
IB impossible. At tJiis <^ftr1y period we can only detect the ex^pas of catarrh, 
and unleBH tbe complaint i^i larg^ prevalent al the time, or other chilih^eu 
in Uio house are euffmn^ from pertussis, there is abeoliitcly notliing to 
nuko uit f \«ii aufijiect ite existence. Often, towards the end of this stage, 
' tbe frt^tiitcuRv and peiHibar %-iolejice of tJie flta of coitgfaing may rouse our 
BuupidoiiH. and if a genuine iMtroxysm oneur. doubt, of nourw, csasu to 
be potfcible. But aUbouj.'b fully developed wbooping-«o«ph cannot be mjs- 
bikcit, thn inrMlilied fonn of rough which is oft4>n all that \re am detect 
mny be onxily TiiiBititoqtiTtcd. A more or less prolonged omipb with a 
faint wtioop iT<sn\ idtght ]ar_\-nf>iml Kpnurn ia not very itncomnion in n ehild 
HUlfcriDf; from clicsl complnint, aa<l an a1x>rtire pt;rtu«>dii may aoii)ctini(.-9 
gim rise to no more cUnmcteristic B)-nii>tonu9 than these. In nuiking tbe 
dlstinRtion no nrgumenta drawn from uie aeutenecn of the attack or tba 
(Mu-ly ^Tio<:l At whicli the eougb awuined tbe Bpssaiodic cbnmcter cad b« 
reliutl upon, for modi&pd jM^rtuann may be as sli^bt and transient ns any 
mere pulmonary catnrrb. It is of fiu* ■n'eater importance to notice Ibat in 
a milii form of whooping-cough the general health is good, and that an 
examination of tlic cbest re^eaJa Utile deviation from tlie Dormal state of 
tbinga ; while a chost afiVwtion aufliciently mrioiin to prodnoe an imitation 
of wtioi>uiug-('ou^h will iiijiirf' the gcncnu health and modify* the physical 
signs. It iH usually in catiuxhal pneumoma that this violent prolonged 
cougli is notireil. In such cases we find the symptoms nnd plijsiral .>iigns 
of ttiiii disenw!, and wo exclude pertutwis by roniiuking t)mt liie ciiii|:;b did 
not Ixoonie pftroxytiiiiiU nntil the ohest di»cai«^ won well dewloped. In a 
case of n-id pcrtuHms witli Kecondarr catarrhal pnmimonia, the rbnnictcr- 
istic rough is Terjr mucb modified immediately the complication Iwgius, 
ParoxyHma of viofont cough with Home spasm of tbe larynx are often no- 
ticed in cases of oolaii^uieQt of tbe broci-hial glands. But here wo get 
other »igUH of pressure upon the pneumogaatric nerro: tbo broatliiog is 
more or le«B oppressed and tbe voice is thick and hoarse between tbe 
attacks of cough. Besides, tbe venous radicles of the face, neck, and ehesl 
arc utiiially more visible than natuml from premnre M]xm tbe innominato 

wn oopnro-coDO H— DLAOJfoaia— p H00N08IS. 


: Uicrc ta DO expeoforaiion of ropy tuuniH : nnd the (Hsease ia anl 
tpable of beiiif{ corninnnicated to oUier cLUdren. 

WlwD cou'.TilJBioiiK occur in a ctum of wbcK>piug-<!uugIi it is yery iniiwr- 
tAEit, vrith a view to pi-ogooeis, to nscextain their uiotle of origiu. If Iho 
couTulaiou h tivmptomittic o( the onset of an i [lilitiumutur^- (xjiiiplii-ation. it 
is aoooiaiiiuuMl hj a ri«e of t«m{)enitMre tmii fuUowetl by s iliiuiiuitjon iii 
the opanaodic symptomm and a modifleatioD of the phmcn) sififns iu the 
diest tf it uinouacea the ocxarrenoe of mllnpae of the luug, tue chanu> 
tAiistip symjitoiiiH wliich tuark that IphIoii wilt be preseat 

If Cbfl oODTalsioD ar'vto» from oxn]<gi3nition of the d«tvous disttirlxuice 
which is one of the peculiarities of tiic diircast', it will hare been preceiied 
bjrsigiM of unuminl a^tfltinn in fonnrr fita of coughing. Sudi seixureit are 
odIv Men iu (!hiltlron known to bn iiervoiiR, Honftitivo, noii inipressionabkt ; 
they follow imiuedtntviT upon the couf^b, aud botwMH Uxo attuckii uo 
Btnu of ucrvDUH ■listurbuiit.-o remain. So also in the case of convulnions 
ahsiDg from partial asphyxia : the nervous attack Ls esdUni bv axtreme 
Tiiilence of Bpaam, but after tJie lit lioa powu-d off no fii^s of cerebral 
Icetou aro Left behiu^L if, aflvr a 6t, thuru is Bquintiug. drowxiiii'tHs 
stapOT, or other m^n of uervoua lUsturbuiice. we may fear that c-ougeHtiuu 
of brain is present or that tliroiuboaia uf tlie c.-ei«braf HinuHea has oo-urred, 
and should watoh the case with ^rove apprt-Uouaiou. 

/Vwf/iiosM. — Wliaterer lie ttie ftfje of tL« rhild. Ibc prognosis is tarour- 
afalo so long rw Uie disease reiiitiitm iiucouiplioattHl ; but if a couipliraltou 
•rise the prospect is lens hopefitl, nnd in a Y«ry young child aar addition 
to Uie oortnal rourse of th« romphunt in to be regarded witli anxiiily. 
Oonvolsioiis, bronc^hitia with collapse, ajid catarriial poeunioQia are the 
principal cnmea of an unfaTournble iamie to Uie dtsaase^ 

In the coso of conTuhiiuiitt. if the attack can be coatMded vith nen'ous 
■ptatkm or the onaat of an inflamntatory complirntiiw. or if. aft«r Ihc fit, 
t£s diild seem bright and well, there is still room for favourable aulti-ipn- 
tioii. If, however, th« seizure m syuiptomatio of dilTuaed piilraonary col- 
Ispse ; if it (k-cut iu the course of an oxtcnaive puliuuiuirj' iiiHouinrntion ; 
or if it be foUowed by drowaniuvi, Bquintiiig, or iti^^a of cerebral lesion, 
there is little proaj)ect of the oluld'a recovery. Somc^times w© can ontici- 
pste the ocourreuce of oonmlsious. If we lin<l the child to W nerrous and 
unprsstioDAlih!', awl we notice that he dIspU;t'8 uutifliml agitation and ex- 
rttetnent on the niipronch of the paroxysm, n-e mny bo prepared for an 
attack. So also if we find that the face becomes'very oluo during the 
ooagh. and that the npasni of tlie larynx is uitusimlly prolonged, wc may 
Imt that an eclamptic nttook may ensue. Lsin,-ngisinu8 HtridnliiH, ax it 
■Of^M an wlditiMial obstacle to 'the (U-ration of the blood and t^-nda to 
pnimat« coUapifc of tbo lung, ia nn unfavonrablo stpn. If it occur iu 
CDrabiuatiou with estettsive lung misciiief, tlie jirosfjeft is a rerj' hope- 

If the pulmonary catorrli becomes uf^gmrati-d, thf presence or absence 
of rickets is a vcrr important inaUi-r. Softcuingof rilxi is a great obatade 
to efficif^nt bniiilhing ; and if the ppeseiice of thick mucuH in tlie tubeK pro- 
xies at) additional impedittK'iit to the eatnuioe of air, the occiirre»c4> of 
aoUapete ia iuuniueiit If. with this, the spasms ore violent, and the eliiltl 
■eem much exhausted at the end of the 6t of mushing, collapse n( the lung 
nay bo considered ineritable. In such a o^ tlie prognostti ir a verj 
gtoomy one. 

If the catarrh pam to the small air-tubcti and TetdclFK. and set up calar- 
dial nifitmioiua, tha state of the child is serious, ^till, if the patient b» 



)( b&alth^ oonstitatioD and tbe portumu of compMutJTal.v mild type, lie 
luLH a chance of recovery. Iii a. rickety child tbe prtwjwct U «(»rv bou. In 
ou<> of Rcrofuloux couslitutioD, if he do not BU(.><mtulj Luim«tiAt«)y, there- in 
ovcrr likoJihood that a chrome cooaoUdatioD of ooe or both Luugs will be 
left liebind. 

TWatmmt. — Tbe treatment of wbooping^cougfa reMilvn il«filf into gen- 
era] Bteasures for prereiitiog coDmlimtioDs nod furthering the normd 
worldiig of the uuimal funotionii ; uiiao, in ttpcdal Irontmcnt lor BhorteuiBg 
Ihe diiuBite and diininjabiup Woknce nf Hpasm. 

If possible, the cliil<l Hbould be eoitfinftd to two rooiiu) npcnin)* into ons 
Auother, so that hu muv iuhubit them oltc-tuntcly, iiud f^K^l tlic bcui-Bt of effi- 
cient vKDtiliitiou, Drnuphts aliould be nvoidod. and ibo t<-'mi>cratutp be kept 
as nearly as possible at i'lH I-'nlir. If the n>onis have no tloor of conimuui- 
i«atioii, tbe child ehouli bo taken trom one to ouotber, wrapped from b«ad to 
''lout iu u bhudiDt. Ni^xt. quiet and the oTuidnnc-o of all murcea of excite- 
ment and irritation Khoidd be eutorcwl. If old enough to be luntued, 
quiet gmues ncd piotitrD-l>ookR may be supplied ; and a tenchablo child tq 
not to be vroirivd with li-nitoiitt if Le i» diniiiclined for them. Uis 
ahould be stntablc to the xeiuiui], but bare anas and lepis must be fo 
dPU, and the cht^at sboul^l be covered nitU cottou-wfiddiug if the weather 
"be chaogeable or cold. 

In re^ilating the iliet oaj"!! should l>e talcen not to overload the fltom* 
aob. I''our Riiinll nieais nn* better than three largo nneft. nnd attoution 
must lie [jaiil to the patient's pnn'or of dif^Mtin^ femi«ntabIo arttclea of 
~Dod. Tbe miiciiii llux from the atoouich and bowvlfli which ia a prnminent 
euture of the complaint, in an acti^'e agent iu proiuotiufr aculity; and 
stitrcbee must Ite given, therefore, cniilioiiijy and in limited i[uanti1ii>ti. A 
1>abY does well upon milk and biirlcv-watvr (equal parte), aih) Mclliu'a 
1, with a piucb of bicurbontit*.^ of sodii to ciicb bottle. He maj' alao 
ive the yolk uf au egg tuice a uef k, and. if over ten miiutbti old. weak veel 
chicken broth once in the <biy. iiter eighteen months tbe child may 
ive ntinced meat, or lasii, milk, e^'^ and otjile bread, but potatoes and, 
rinaceous puddings are to W avtiidwl. AVell biiiled cauliflower or i 
ay Ix* given if the jtatient will tnk* tlieiu. 
If the natural voiuitiug does not suf&ciently unload the dtomacb of mu- 
cua, nature may be aided by the occasional adniinuitration of im emetic 
Sulpliate of copper, rut reconimcndcd by Trouseean, is very use-fal for thia 
purpose, and niay W given to n child of one year old in doaea of half a 
jrftin CTcrj' tt-n miuutea tintU sickness is pnjdiiccd. Also, it is well to rc» 
peve tlie bon-ebi by an occamotud duse of cJiMtor-oil. Looaeneas of the boir- 
Buch aa is common in thi^ comphiint, ia at once arreted in moat eases 
by a dose of thiti useful remedy. 

Uf Mpeeial dniga for ttliorleuing the attack and relieving apsion, no many 

have beoD recomiapmUtt tluit tbe mere emimenition of them would onnipy 

many lines ; but of really ecrviceablo drugs the nurabor is much more Um- 

itcti. Tlie treatment I liave mj-aelf found to be moat uacful, tuid now iu%-a- 

jrjably adopt, in the following : ' — Du-ectly any |>eculiarity in tbe cough or 

~lao ooourroneo of sptum indicntm the nature of the compluiut, I at onoa;] 

jegin the odnumaChition of sutphato of zinc and atropia. From a large' 

experience of this combmation I can apeak podtiwlj aa to its power of 

' jvuucing Hpasm and shorteDtng the dtaeoae. I begin with oite-«<ixtb ot m 

Ijgraiu of Hul]>hate of zinc and half a drop of the solution of ntropine (P, B.) 

■ Tbe quaatiUea rcvomioeudcd an saltoUe to « ct^ld tw»lv« moatlu oC ige. 



' Bweeteneil with glycerine, each morning an<l evening for two dayn, 
heti tliivft tiiucs n (litT. After r n'^ek Uie quimtitj of zino in increniMMl 
to on*-fourth, imd still WU^t to oTMN-thinl of a grain. TIid atmpiii, how- 
ever, is gmn in frcquonLlT incrcoiiiiig quontitiet. Cfaildn-n, lUtbuu^b Uiejr 
■rtay in tlieir iiiKiuiceptibility to tlii» drug, con oU take it tu lui^u (low* ; 
ikod in whonpinp-rouirli where there in opaain to be oreroome, the remedy 
in of little value uulcw givc^n ia dosee wimcaeDtl,? large to produce some of 
the phrHiological efiiecto of the edkaloid. Escludiu^ the bcUtuloDna rmh, 
whicn 18 too nDOertain in its appeamnee to 1x> tnutted, dilatiitiou of the 
popil is the earliefit eyniptou (luit tho (ivstem in reeposding to the ai'lion 
of tlie iae<liriiic. This ai^i is af parattHl l>y a wide interval from the next 
MiHieat 8)'niptoio — ilrvtioa* of the throat. To W of aen-ice, the reni«Kly 
^oulil be piifthod 60 sw to tirndut'c eoinc olToot upon tlw piipiL With this 
olijoct tlio dose should be mcrMaed erex^ two Atkvd by a quarter of a drop 
of the atropine snhition, wat«:hiiip the effect, in this way, mth pei'fect 
Itafetv, largo qitantitioR of the drug may be administered ; and no emiilnved, 
I think DO doubt enn Ix) cnttrtAincd lui to tho valno of tli<^ treatment (uid 
ila tufluGQCti in Hhortmint; tho courw of the Bpasniodic ittage und rcducinR 
the violence of the aLta<!k8. If tlie t^asm is exceptionally severe and seemn 
to threaten partial aiiphyxia, it ia wise lo gire in adilition a nightly dose of 
bromide of potattsiuin or ammonium (gr. iij.-iv,). There ia one prt'cautiou 
which it JHwi-ll to udopi during thimtttage. The [jarus^i-tinm are ofivu moot 
frequent and u^vere at night wbeo tbe child is anledp. The slighteat move, 
ment of air acroes the face, sadi ifl ia produced by a person walking near 
the cot, will off^n eitrite an attack. These night aeizurea can uoually be 
naatly reduced in nunibfir by an expedient miggertwl, I l>elieve, oiiginally 
by Dr. MnrKhftll Hall. It oon»ri«t« in tlirowing n fin« iniixUn ciirlnin over 
the cot at mt;ht/-tiBio. The simplcut phm is to have a couple of h<K)ps ar- 
ranged at the eodfl of the cot, like tlie " tiltn " of a wagon, bo an to siipport 
Hie eurtoin at a aufficient height TIur arrangnment, which correK|)ond9 
to the mosquito curtain u»«d ia hot clitnutca, doea not iulc-rfci-o with a 
free supply of oxygen, while it effectually BtotM all wimdcriug curreutfi 
of air. So protected, a ohild will often aloep the night through without 
oa attaok. 

At tbe end of tlie Bpnsniodic atage and daring the period of decline 
aliun is very t>eDeficaa]. T1u» remedy, Qntt reeommcndfld by Dr. OoIJing 
Bird in IMS, luw a marked iufluenre in <-hcckiQg too copious secruttoa and 
bringing the disease to a farourablo ternunntiou. Two or three grains of 
alum may he substituted for the sulphnte of zinc in the atropia mixture, 
and given thn>e timei* in the ilay. It \» at thiii time, riz., tho end of the 
qaaamodic stage and d\ihng the period of deohnc, that 1 have found the 
unine treatntout cBpct-ially uai'ful. I hiivc htUc csperiencc of the drug 
Uw beginning of an attatk. According to Binz, Janaen, and others, 

I'Vfao, following the HUpgestion of Lelzerich, direct their attackaagaintit the 
argaaista whicli htm been snpposr^d to cjiubo wljuuping-cuugL, quinine 
Jiren at the beginning of the iUiiesii inippniMfs alt^igvtlicr the sjuLimoilic 
pnt, and eoiiverts the disease into n severe but manageable bron- 

fchitts- They recommend the comparatively Lastelees tauuate of ([uinitie, 
giren twice a day in doses of a grain aocl a half for ereiT year of tbe 

Then is no doubt tliat to be efficient in pertueais nuinine ahoald be 
grreo in full dosea. I have given three times a day two grains of the aolphate 
of quinine to children between fwelre montha and two yeara old towards 
tl» end of tbe apamuidiR atnge, and li.ive tliought that the discaao was cut 



abort hy tbis meaoa Anollit^r couibinntinn which acts aomctiiiMB ot Uu" 
period of the iUoen ^th nontlc rful promptiLiitlo \s fonnod hf adding two 
ciropit of the tinctiiro of cAnthariiles lo five dropti cnch of thf tincturr of 
ciofjionft and [laregoric, and giving tbts done three tiinen a day. Tonicn 
generally an> UHeful iluriii^ tlie Klitf,'R of drclina The prepsnUions of iron 
ore CBpeciaUy valoable. Thirty drojw each of the oompound decoction of 
aloes and iron wine make a good nimljimtUou ; i<idide of iron ifl ot Berrietf, 
and the eitnUe of iron n-ith an aliali may be resortod to. It is a matter 
of fpKAt practicid inaportnzico in all thaie caseA to avoid t))« use of wpraya 
in sweetening the misturc for the iufaat's palate Qtycoriob, beinf: iiou- 
fermentJiUe, is far safer ; or we may use a few drops of chloric etli«r for 
thi» pitrpoRC. 

3ilauy otJier drugs are used in tbe treatment of wboopine^ou^ The 
old Ln.-jttmi-nl by duiite hydrocyanic arid nnd that by ifilute uibic add, 
each of wliii-h has had its dftv, has now. probably, faUi-n into complete dis- 
use. Opitun, however, in some form has r»ot been completely superseded 
by belhitloniia. The propai-ationa of nioipkia nre Btjll n lied ii[>(tu by eomo 
practitiouent, and the remedy is Do douot a uttefiU one. It should bo 
given in sufficient dofK'Ji to produon sligtit drowsiupss, and thia effect 
fihould bo mjitutuiucd fur iKvcnd days. For a child of twelve months a 
drop of tlie morphia solution (P. R) can be Riven even- four houm. There 
Ik do doubt tbat the spaHm con be reduced by this meana ; Itnt the treai- 
UMint is, in my opmion, inferior to that by atropine, and uoccasilatee rtxyi 
careful 'ATitchiu^ of the patient Ivai the nuix-ulic effect of the remedy mq 
earned further than is detdred Cltlurul may be ahto employed to reduce ' 
apasm in dosea of gr. ij. every four or six hount. It is sometimes tteed in 
coiuliinatiou witli bnimide of potaasium, and the cQectof butb drnRH ap* 
iwiirs lo be heiyht«netl by the aasodatioD. Croton chlond is a remedy 
prwitly pt'liwl upon by souio pmetitionera. The doee is one gniin for \ 
clukl of twelve montha, given every four, six, or eight hours in wat 
■weetened witli g!y<'«rine. 

Ilosidos LliL' ubove methods of troatment tlto topical action of dru^ 
is Ifli^ly used in tho itMiugement of whoopbg-coticb. It ia now 
nearly thirty years mnce Dr. Ebcn M'atimn advocates swabbtug tha 
Inr^'nx witli a nolntion of nitrate of silver, twenty grains to Uw oimcoJ 
The application was repcAt«<l evioy aeoond ilay, nnd the qwsDi is said 
to have auhaided at tho end of tlto week. Thin heroic remedy is not 
Dovr in vogua Instead, milder applications sprayed into the Uiroat are 
made use of. A two [x-r cent solution of salioylio add uaed regtdarlv in 
tliia nianner is euid to dimiui»b ni])itUy thv number of pflro^-sms. Dr. 
B. J. id n warni advornte of carbolic acid inhalations, and claims for) 
thorn that they induce a daily decrease in tbc riolencp of the cough, : 
promote tho duappoaraoM of tin Brmptoms within n period Tamii|; fi 
a fortnifrlit to thn-e weeks. Dr. Lee prefom lunff-coutinuod inhalations of 
a dilutc'il vapour, and reeomiuenda that the air of the nxnn should be kept 
aatunt.t<-<l with a wcnk soUition of carbolic add. Aa tliia acid does not 
ernpurute when esposExl to the air, special means have to be used for con* 
i-erting it into vapour. Dr. Lee'B " steam draft inhaler.*' which moil 
tho air as well as m&dicatcs it, is n useful and simple spporatua. A sohi*^ 
tion of one part of tlio ucid to thirty of water is to be \tiK-d for rapora*-.) 
tion, and by tlus means tlie child may paas a large part of his time is air 
kept satuf^ed with a dilate roetlicatel vapnur. If carbolic acid be in- 
haled in tbe onlinar^' way lirom a mouUi-picce, tho solution should Dot be 
atrouger titan one part in eighty purta of water. 

External applicationa hare cot been ucgluctetl in Ibe iriAtnititit of 
wliuo{iini;-cuut;b. Mimy patent rem«<UpH, Hack ta Bocbe's eaibrucaUon, 
whi«h ifi composeit of the oils of elorea antt amber with double their quan- 
tity of oliTe-oU, belon;; to this clafe. Stimulating lifiiioenta are often naftTiil 
if tht* ratJUTb t^ th« cfawt is mverv, and H »ppiifeA aloDg the aidw of Ui« 
neck, uid to tho tipiii* mi w«11 as to tli« ohcst, may tiel]> tn n>duc« tin npaaat. 
Unattttd poulbeM to tba back oro fftTcmril* nuueUics witli boum pneti- 
tianerfs and it in saiil that if appHed along tin- vihuh^ IcnKtli of tlie fipine for 
six or ei(^t miuutes erety mgitt before tbe child in put to tied a speedy im< 
prDTSSieiit i» notic«d in the 8>-inptom& 

Wbcn vomplicatious nriM-- iu the eoiirse of wlwiopiujr-cmi;;!!, spLfia) 
measures muxl. he lulnptMl fur thi'ir rvlief. If tbt? vomiting u( fuucl heconte 
exce*mre, no lu to iuttrferf Ht>houiily ■with thL> child's uutritiuu, it may be 
often rvliereil bj emetics of Butptiate of copper (half « grain to the le«- 
HKwnful) given uverr duy or on alternate aft,v8, so n8 to clear awaj' ten»- 
aoQA muoui from the stomach. Chloral is luwfitl in these caws bj its 
power of dinuoishini! reflex action. Excessive vocittini; ijs ubhaUt' fnitnd 
m coses where tbe larjn^Bal HpaHin ih extreme, anil the remedies which 
u« useful in alleviating thii« symptom hnvo nlso a beitefioial action in 
ebMluBf Coo forcible coLtmction of the dinphmgm. Loommw of tbe 
boivc-la in uDunllv licuflly coutroUud by a doBo of uiator-oiL In this coun- 
trr diarrhii;a Hcldom becomDs ti'Dublesome, but in warm climates during 
UiH hot season choleraic diarrha>a may aoperveiie. TIiir must be tn^ated 
AAconUu); to tbe rules laid down for tbe taam^,'emcIlt uf tbut m-rious vou- 

If laryngiKmuK stridulus compUcate the piUTSiysm, bromide of am- 
tnoniuni or potassium (gr. iij.) may be given with atropia two or ttiree 
timee a day ; and the same Irentmeni in uRefid if nnvroiited nervoufi excite- 
meet, or sisrns of cerpbral di.H turban ire, indicate the iiuinitieiif* of a ronnd- 
nv« fiL If the sjxuim Ite pix)lon^rtl fmtl seem to Ijireaton sulTovAlion, ttlip- 
pu)^ the cbild'if hands into cold wukr vriii oitca mlax tbt' glottii) at once. 

ConvidHionK muitt bo iruatcd at-t-ordiug to the Bperuil condition from 
which they appt'nr to liave ariEeu. In the more aerinaH form of eclnrnptin 
attack, Buch aa that induce<l by collapse of long, catnrrlial pneumonia, or 
UiromboeiBof inlracraniol sLuuaea and veins, the treatment mustbedu-ectod 
agmnst Ute oomphcatiou by which tbe uen'ouH seizure hax beL>n excited. 
[Oonvaledons BOt up by puro uen-ouB ngitatiou, or by partial anphyiiR from 
▼iolenc-e of laryugeal s^jai^m. arc usually to be controlled by the admiuistra- 
tion of chloral iu the (|unntilie.i nirewly iQdii.-ate<.l. If the seizures nerur in n 
ricke^ chihhand appear to be tho cousctiuence of dige»liv<> diKtnrbaooo 
Mul acidity (a not uncommon case), a dose of ipecacuanba xriat/, followed 
by nn antacid and aromatic mixture, will usually put an end to tltom at 

If the pulmniiiiry catarrh bccoino ativtiv and tlirwtton nnllapse of tho 
lunKt prompt ntvpn must bo taken to war<I off tliis dani;;erau8 complication. 
StixaulatiiiK upphcationa should be applied to the chest and hack ; occa- 
Bonal emetics ijiould he given to aid in the expulsion of mucus ; and the 
child's strengtb miut be supported by a suitable supply of alcoboUc stim- 
ulant. In these cases alcohol ahould be i;iven boldly. A young child iu a 
waakly state from acute duMKise will reKpond well to sucih treatment, and 
A few timely <1ob*h of brandy-and-egg, or other powerful atimulaut, will 
I quickly give him renewed 8tre-uKtli to struggle against his disease. It may 
Iif necewnry to ^ve a teaspooufid every hour, or even half hour, until th^ 
diffiriUly it* oveivomo. 



If catarrhal iTfiT^'* flU})erveii«, tho eomptication miut be trciieSl 
upon tlio princi[^ Uid down in the chapter rehitiog to tlut Bubjed 

Vrlien tbo (Ummwa k Bt ao eod, chuigf* of nir to n dry, bntciiiff spot or 
to the seo-eido is of Importance. ReraomlK'rtiig tb« &«queti«T d glandular 
snLkTgaraaDtB and the anncrer of tubercaloHui, ne eboula reootniiiewl such 
m«asiire8 u ore required for reatormg impaired outrition and replacing 
lost fltreogth. Ood-liter oil u very vitlonlilc, nlcobol is of nnio*, and iron 
ifi UBiudly indicated. 

Tlie HjinpU>m» de»nri1>«d as " mucouH dlaeaM," vhich are often seen in 
ohUdrcn o( three or four yearsof iig« or upward* aft^-r an attack of wbooit- 
inff-Qougfa, arc cniicklj remored hy careful regulatioa of tbo dirt. Tbo 
cbilii Hhould be led tiix>n loeaty oggB, fiah, poultry, and milk ; and potatoea* 
ffirinju<(in)ii4 puidinf^ fniit> ci^Eea, eweet* — all artioJes, in ^t, capable of ' 
affQt>lin|i QUiterial for fermentation must tw ttncUy CorbiddAB. A mild 
uiM^iitinC auch oh the compouud Uquorioe powder, should be eiren twice a 
week to ensure the cxpuliuoii of excees of mucus from the bowels ; and 
iron with alkalies, or iron wine with compound dceoction of aloea (U 3 ij- 
for i> child of five yean of ogeX ahould be giren two or three times a day, 
two bouiD after meak. 

Or ftU tlie ehronio duwaes to which roucff children ore liable, none bus 
pAMK-s iu inlertat taiii imptirtnucc tbu ouo ao«r to bi- ronsideriHl. The frfr* 
<IUHUC}- vritL which rioketu oocui-k, Uk ^-1uiety uf titwueH it (LlTi*ct«, the iufla- 
etK^e it HXerciuea upon the coiiFHe imd terminntion of inlert'iirrODt nialadio^ 
And Hie 'lUtreaaing aod often fatal coDdetiueaoes which its pi-eeenoe ihyoIvw 
ivnder this liiaeue especually dflwrriii^ of careful study. 

d\]thoagh dissiiuilAr in iiianr reH|M>c1a from the c\ite» of Ho-CAlleil dia- 
thetic disMses, viz., thoee which ariue an a consei^ueiioo of a distinct con- 
•titutional proili.<4]>o9itinn, rirJfelfl in yet n gfimnil aHVrtioii. for it impniiB 
the iiutritioii of thn wholn l>ody. Umliir iln iiilliit>nR(! )^wl.h and develnp- 
mt'Ot arfi anvijtJi-d, 'loiitition is rptiuded, the boiiCK soften imd bci^omo 
dofonncd, the ruu&eU<a luid lii^mneiita vrafite, and in fiitjd cast* nltDmtioii« 
are ofl«ii noticed in the brain, liver, splf^n, and Ivmpliatic Kl^Dda. The 
d\aeafw usually bcginii in iiiftuioy. It in rart^ iiikIit Iha aga nf six month^ 
tor it scciii.s very douhtfid if the cases of uo-cniltxl coD^auitul rickiil^ ihro 
true fxiiuiptva of the disciuie. At llio eiffhth uiouth, however, it btiRins to 
be comtuon, anil from tliat age until the eighteenth mouUi may be readily 
B«t up under the influence of cauaea which iiilerfero with dijjeation and im- 
pede the aasiniilntiou of food. It it li-ssL-omuioiifor the diaciwu to d«-veIo]> 
in cfatldrfu wIk> have been iu ^i>ud heiilth up Ui Ltie age of eightuGu moutlw, 
bnt it mar ow^ur at any timo between that age and the aevpnth year, op 
even in still older xubjectit. Altlioii^h be^iiiiiiii>j[ at a very eaijy a^'e, tlie> 
ilitM^aw oftf^i <v>ntitiiifH fur «ov<-nil years, luul tuny be seen existing iu a 
nuirlcod defrrc* ii> cbildrcti Uin-e or fmir vf ars old. 

f.h'iivili"iK — R^kcta is tha direct consequence of nml-nutrition in early 
life, Hs cniifteH muHt iJiei-efore he loolicd for in nil tJiH diverse atfeuctes 
which impair the DUtritlou of th« growiuR frame. Tho nuKt iiii[M)rtant of 
ttMM ftr«. no doubt, fnuItA of fcodin|:r and bv^ieno. Inituflicient or unsuit- 
able fbod atints tha body of ncccasai'y nouri»hmcDt, and an inadequale 
•npjjy of frvah air renders aiudmilation defective and weakens di^eali^'e 
■povtr. These two cnunest are most commonly found united in llie uoorst* 
4{uart4.'n) of lu^ citiCH. .Ajt tuEout who lived auiOBg»t other childreiki 



one email room, wh^re it breatbitn a tainted air luid dorivt-H its onl.r Donr- 
isluuenl from tli<> wat«inr lireatit-milh of a wcAklv inotlur, uilli Lho tuldi- 
tion, iw^r)ia.iM. of 4 little gni^l or ttopiM-d bn-ml to ijuifcl it wlieii itmes, coo , 
oq1>' Hjicjtpo nek«ti' b; beoomiog tubt^rculnr. ll,v Kueli niMutM ilq extreme de- 
ffTM of th« siaIkIt will i)robflbljr bo pKH.Iuce(l. But eimlUr ii^-Dci««. «1- 
tiir>U{;h opvnitiug in a milder form, will pi-odiice rickets in anj oouditioo 
of life. It iH not uncommon to meet with •xnnipleH of the disease in well> 
to-<lo fumilicfi where the child bos been kept in-^oorK for fear of his catcli- 
iuf; cold, uud baa boen supplied with fannaceoun cuuipouiidtt largel> beyond 
biK [wwfin uf digcstioii. Over-feeding witb starcliy food» is b fruitful 
(stiiK.' of ricketa Tbo giriu^ uf fai-imu>4K)iui iiiattere in esce»i, or at a time 
wheu the glandular Aecrctioud iiri.- iu&tiQivk-nt for its digestion, is the coiu> 
nioiRtit fault L'ouiuitttil in tlit^i Uauil-fiftlliiK of iufaiit^. Dr. BudianaQ' 
Ba\I«r, who t3bulnt4.1l oue liuudred aitd twenty (*oii(ieculive ctises uf 
rickets, found that iu mtmy of tbeui the <tiBea&e dated from the time when 
farinaneouB fooal was iimt ^nwu. It iit probablv that in theee oaees the 00 
ciirreiicte of mal-nutrition and KuljM-cjui'ut ricki-tx in due not eo mtu'h to 
ttiu i*S(.-«K8 of )4tai-cb an to the abaence of thf more uuthtiouK food for 
whicJi the atarch has been aubatituteii lUfkety t-hildren 50 fed aro often 
fat, and do not, tn the inespenenceil eye. convey the impresaion of being 
iindor-nomiRhed. I'lxaniiniLtioii. lioweror, disoofora that they are by no 
monnn strong in proportion to their eiae, Altbouffh etout Uioy ore -weak, 
often excessively feublK ; and it is evident that the plumpnest of the ctuld 
is due to diitproportiunate deTelopnicnt of the BubculuneouH fat This 
tissue baa been cuormoiialy OTcr-nourialied while the reat of the body baa 
been diluted and etarved. 

The time of weauinjj: in uften a Ht:iu-liiit;-point for ricket«, for tlie breast- 
milk ifi usiuilly re)>hu.f!d by eotiie pi-eptu-iitiun uf Htarch. So also loiig- 
coutiuued suckUug may Uidticv the dUeaae, for the bi'east-uiilk after a 
tdmf! reoAes lo sittiafy tlif iiifaut'it wants, and too little ai.ldttio[ial nouriiih- 
ment is ttiipplieil. Therefore whether the foo<.l given be iuBiiffioient in 
amotmt or indigeirtible in form the efi'oct is the same : the diild ttt atarvcd 
and rickets hororaes developed. 

In cases where the child lives in A good bracing air the efiects of an un- 
RQiUble diolory am loiM painfullr cvideot. In dry eonnlry ploeea, where 
the infant Hpvuda much of his time out uf doont, rickets iB a more uncom- 
mon disease than it is in locahtieH where the eonditions are less (arourable 
to health. Want of sunlight, want of eJeaidiness, and a oombinatiou of 
cold and <lninp ore other detcrmiuiug causes which are not without their 
iuftucnoe in the productiou uf hcketx. All these- cuuaeH must uo doubt act 
with espMTtid fnor^' iu the citse of infnnta who are naturally weakly, or 
whose streugth has been already reJueed by some eKliaustiug diaeaeo. 
There are, therefore, many conditiouH which pn-ilispojie to the oomplaioL 
Feebleness of couHtitution ou the part of the pjLrent« will, no doubC have 
an indueuce in this respect, fur weakly parents are not hkely to beget con- ; 
slittitiounlly healthy children. Moj-eover, n woakly mother is usiudly unabla 
to nm-Kc her haby ; and hand-feediag, uuLens couducled with extreme cara^ 
and tliHcietion, in often imaatisfnctory. A. very Lugo proportion of ricket)' 
Lubint£ nro bottle-fed. 

Horeditarb- teodenry is considereil by some obserrera to be an clement 
in ihe etiolocy of the disease. In ihe cum of so common an afitzcdun it 
must no doubt often lia]ipen that the father or motlior of Uie patient luui 
been prenoti»ly affeelefl iu a. siinilar nny ; but that u paroiil who Uoil been 
rickety in childhoud hhould give birth to a weakly tnfint, uod that this in- 

bnK brouglil up in violiitiou of nit tJic tuIph of hRtiltli, xhotild ileve1op« 
rickete^ is tuirely but steiider endoiirc in fnvnur nf thti hcit'ditarT trans- 
missitiii of the t.lUe<»«e. Supp<ji-ten» ol thitt titt-orj asuallv ixiiul to llie 
cnn« of iiOHsalitxl "couKfiiiiiil rickt-b*" iw imttutices of the inut^riterl fonn 
of the dueuiM ; but, un is hKrvtitter expluiue<(), there are rciutons for excluiU 
iDg the»e t-aaee frotn the daiu oi tine nckcts. 

Tlic n-liitioii wliicli exwts Wttvi-eu rick«1ti and coDROtiilul Bj-^tUUis hiui 
vritliin tltf liut ft<w yviirn boitu bruu<;Lt uiUi (^reat pmminptiae. >C. Parrot 
lisx labuurml to show tlukt hrkt^^tH in altvuv)) liie foaaoqiienca of an hriv^li- 
tary 8y))liiLtii^ Uint. Tlie Hi-;;tMi]eulh of tliis olieenfr iu fuTt^ of bi» view 
ai*- ilcrived rliit^Jlj- fnnii iiimbi'l ftuatomy, Hv poiiiUin piiHiciiW to the 
fUiAU)riiic:ii cii'«ii;.'t'S ubtwrvnlilo in tli(> t'pi[)l]y>><'!Ll irnds of tbe long boueR ia 
tlio two tUwifTcii an criileuce of tba 8i>ccific uatiirt; of rickets. But tliv litttdr 
IB not ufi'v a ()i(ieii.t(! of tlie bonex; ami altliouyib the epipliyiteH in Ibe two 
conefttnAy iH-GRRiitn uortaiu KUuilniity ofiesiou, tbemurootber ultei-atioiiKOt 
stracture in ri»>t» vrUicb are different from, those ol eyphiUs. Moreover, 
the <;euiiniJ iqrtiinlotDH, especinlly tJie (leriiliar tendency to fuuctioiial ner- 
Toiu diliorders, have no counterpart in the ttpecihc diseotte. A^iiin, rickets 
is eouaUuitly met with tii cases whore tlifi most ctircful inquiry nnd most 
minute csatuiunliuu fail to detect luiy history of venereal tiUiit in the 
pvents or itign uf it iu their ulTsprint;- The diseane in coninion in localitiefl 
where ooucenittl M^-philis is rare, and i-are in places wliore tlie lntt(>j- ix 
common. It is met with in iiiiiiuaU na nvll as thu huuiuu subjvel. and iji 
produced in tlieui by faulty liy;^eue nnd bud fet;diug im it is in the child. 
But it in nec<<11eis)f to multiply injjunieiiLs ngiiiuat the untouiible bTpothesis 
ftdTaiieud by tbiii di»ttiiguuihod pnlliu legist 

Still, olUiou^h it i--atinot be allowed thnt rickets iet enuaed by sypliilifl, 
HVphilitic infanta may hecoiuu rickety ; and it i» pi-obabl<t llnit a parent 
woakeued by » (ortutrr NvuhilJM may, ift4tliuut ti-aneinittinf; th9 taint to hig 
oflbpring, b«;;ut ft child of feeble coniitLlutiou in whom ricketii can be easily 
ioduce<L But in both these rases injudicions feeding and inHanitnry con- 
ditioiui must come into opcaiition bffot>< the diRefute i-au oci;ur. 

A pmionnoed tulwrculur disposition anpcuw to hftv* a protectivo pow«r 
agoiuiit ricki-tji ; for althoitgb w«akly, jybttiisicol parenU may give birth to 
fefrble iufauls who readily fall victiiiiH to rickt^ts, it is raie to find the ha- 
ter disease in a family where other inemberH have died of tulwrculur meu- 
ui^tiri or otJier form oi pure tiibt;rvulutsi» — unlcsH, indvutl, the tiiberoulw 
mischief luui uccmrud iMicomhirily tu lickctN. The rciison of thin immunity 
w«m8 to hi> that the ciiuses uliicb arc vamble of setHug up rickbtu will in- 
duce tnbci-cid.isis in a child predisposed to this form of illness and very 
quickly bring his life to u fltjsf. 

How it i» that ihem cauites give riM< tu rifkvt8 in wtill uudeddnd. It 
law htm shown by tlie experiments of Friedleben tlmt a diet deficient in 
pbospboric acid and tiie lime saltA is not caimble, as was at one time uup- 
poeed. of in<Iuoiog riekMs ; iniloed. it »eemH probable tliat tlie essence of 
Cbo procosB is not n mere deficiency of Itnio in the l)oncs, but. an irritation 
of the booo-making tissue. It is aaaerted by HeitzmaD tliut lactic acid ex- 
erdiWBaD irritating intluc^nce upon the oNteopUstic tissue, and that it ii 
thttf influence, comtiinod with a delit^ii^ncy In limo salts, which induces the 
disease. There in liltlo doubt that luaHc acid is nbunilantly generated in 
the ik-nuigcd iligcstiru organs of ridtet^' chililrcn, for this iifid liiia l»een 
delected in their urine. If Ueitzman'ii theorj* be correct, the acid pK-ites 
irritation in the osteopln.ttic tismie, end at the same time di»»MTC8 and 
belpa to vliuuuuU the calcucvuua matter depoutvd in the bonea If, itt>dr 




on* cmnll room, wh«re it brciitb«>a a tainted nir iui<l dcrivos itA nnlv nour- 
iiihinout (mm l\m vntery brMttt-uiilk of a wt'^nkK' iiiotlit.-i', wilii tli« oilili- 
tiou, pBrbafA. of a little gmtA or eoppMl bn-ml to i)iiitl it wlieti it cries, can 
oiilv escapo ricketfl bv b«<x>miu^ tubureuUr Itv laicb meiuiR od exU'eiue de- 
free of toe luaUd.v will probably be produced. But simUar ngoncies, al- 
UiouRh operating in a luUtler fonu. will pi-odiice hckot« iu aoj cmiditioii 
n( lite It U* not oucommoD to meet n-ith exuiipleii of the diBeaw) in well- 
hMlo fitntilit** whore the child biw been k«pt in-doom for fear of hitt cateb- 
iQlf (.'oM. itud IwH Im<«u aupplivil witli foriufu-coua ooiup<)umU liu-goly bvjond 
liis powi-m of tli|ri>«tioti. Oncr-ft-ediug with (tUrclij- fixKlii ut a fruitful 
eiiuiti* of n<-kelK. 'Ilic t^tvin^ uf buiuaceoua uiattera iu excess, or at a ttnm 
wlifii till- iflitixlular t<c<-rvtiotta tas iiisuf&oi«iit for its digeeliou, is the com* 
inuni^t fMilL rout III illtil iu the luuid-feediug of infauts, Dr Biitdianiui 
Baxter, who tabulniotl one liimdr^ and tweutjr (-oiixeeutivv iwtets of 
rirkctH, fotiti'l that in manv of them the diaease dated from the time when 
fiuiiuircoiih fiMxl wan tiret given. It in probable thiit io these caaee tJie oo 
(.'itrreiice of niKl-iintrition and subsequent rickets ia dne not »o uiuch to 
tliu (xcont of )^tan.'li as to the iibfiiincc of the more uutritioua food for 
wliicli tbv Mtiirch bus bcvu eulwititutcd. Itieketr rhiklrcu eo fed are oFl«m 
fat. nud do not, to Uk- inesperieiired ere, conre; the impretuaou of being 
uiidor-uouritihed. Examination, howovor, discorets that they are by iia 
menus Btroug in nroportioii to tlteir nxe. Although stout they nro weak; 
oftaii exceeeirolj feeble ; and it in crident that the plumpuetst of tbu child 
in due to dit^roportiuuale derelopmeut of the subcutaoeotu fat. Thia 
timue hiu( l)«en enormoualr OTer-aouriahed while the rest of the body haa 
been atiiileit and eturr«d. 

Tbe time of wi-aning ia often a atartiug-point tor rickets, for the breaat- 
niilk ia mnuUlv rt^jilared by 8i.>iiie pretMualion of starch. So also long- 
oontinoAd nu^tliug may iudtiM the disease, for the hreast-milk after a 
time oBaaee Io aataafr tlic iufuit's vrauts, and too Uttle additional itotiriih- 
nieul IH su|>j)lie<l. Therefore ubetlwr the food given be iiisuffieient in 
amount or iniligetttibfe in (omi tlit* i>i4E»ct La the came : the child is starred 
and rickcta Ix-oomcs di-velopi'«L 

In CAM'S wbere tho child li^*e« in a good bracing; air the ejects of an ua> 
■mitable dietary are lees painfully eTiilenl. In dry country places, where 
the infant ^pt-nds much oE hia time out of doorv. rioket* is a more uucom- 
mon disease than it iit in lucaUtiea where the coaditjons Km lew Irnouimbla 
to health. Want of siuiligfat. want of deonliiMaik. *ud a cxHubmstion of 
eold and (.lamp an other detonuiniug csoses which are not without their 
infloeiKie in tm prodnetiDa of riofaets. .\11 these oavses must no doubt act 
with sspeoal eiuvgr in tha oaae of in^ts wba ate natuialljr wewkly, or 
whose strangtfa has bean already reduced by some exhsasting disesBe. 
^MTS arii, tfa«rtlb(«t many cotkdi&ous which fiivdispose to the ooiuplniuL 
FrctOeneoa nf mnstitntkai on the part of the parents will, no doubt, ban 
an iiiHueuev in this re«^t for weakly pareota are not ltk«ty to beget eoa- 
Ktilulioiially bealtfar chddren. Morevifsr. a wedtjy asothsr is ti—tBy waaMiB 
to nun* heir baby : and hnnd-leeding. nnhM eoodncted with extretDO cttrs ' 
ami •liMTi>txin. is often onaatisfaetoi^. X msj Luse pn^KUlkm of rieke^ 
inbcta are bottlMr^l 

Hecvditary irudoikCT ta coMJdored bj aoBM dbmmn Io bo an eletBeal 
in the elinlof:;v' nf the disrom. In the cnas of so cnmnxvi an aflrrtioa it 
rnmt. no doubt ofttin hAppM) that the UUktr *» notbrr of tbe patient lias 
bau |m«KHufar afiMed io a simihu- vn«y ; but tiiat a parent who bad been 
tidw^ in Ailahooil abould gin hinfa to a wwakty intent, and that tlus in- 

Isld*^ bi'ougbt up in vioUtion of all the ruIcA of lutaltli, nhoiild derelopo 
ricketH, in mirely but alemler crideiioe in fiivoiir of ILo bcnxlitorr traus- 
iiiLMKioii of the iliML-iMC. Huj>porten4 uf tliiti tli^or^' uhuiiU^ I3ui)it tn (ho 
ctutcH uf socoUikI ''<?oi)^i>iuInl rk'kete " lu: iiuitfui<.-«a uf the imieriti>tl form 
o( tb© (Uiteiwo ; but, a^ u bereaftei- expUiued, Uier« are readuuti for exclud- 
ing these cnws from flie rlnw) of inie tirkebi 

Tlui I't^liUioii u liU-li tfsixtK tHit-wt^Kti rifk«t8 flud caug«uital s^hiliii haa 
frithiu tht Iwnt (ew yvorB boi-u bryujjbt intw ni'^at protuiueuce. SL J*»iTut 
liAB labnure<1 tn shnw thnt rickfUi m nlwnvK tbt> (-ni)!)eqii<-uce of au bt-i'cdi- 
tarr H\'pliibtic liuitt. Tlte nr^uitiftnis of this obKcnt^r iu fftroMr of bis riuw 
lire ib'rive<l cliiefly fnuii morbid lumtotiiy. Ho ]>o)iit«iii pnmciilnr to tlia 
aiiAtouitnd cUiiu;;cii obiutrrabb^ in tbo epiphii'Menl Piid« of ibe loDg Itonen ia 
tiie two diMMuva :m endeiine of the R^x^rilic iinturR nf n<'l(«(8. But tho latter 
ifl not otiiij u iliitonsK! of the bones ; aii<l iLlthoit^b tb« 4<pi|)hrM« in tli« two 
CMei* luaj prtMcut a L-i-rtntu similarity of Icaiou, tbcro aro other oltoratioos of 
ctruoture iu rifkcia which are different from tho«e nf sj-pbiliH. Moreo»er, 
the geaend ^luptoiuK, especially tiie periiliai- teudency to functioDol ner- 
votu disorders, have no eounterpcu-t iu tho specific disease. ^V^n, rickcti 
lit cou8tiuitl,v met with in comkii where* tbu most corvfuj inquiry' nud most 
minute fxiuitimitiou fail to dfiti^ct. nuy biatory of wtienaul tsiut tu the 
|)-jLT«ntM ur uigii of it iu their ofliiprin^. 'Die disease ia ponimon iu bicalitiea 
where ooiijfeiiiUil Hvpliiliu ia rare, uid tare iu plncv.t where th« httter in 
comtooti. It \h met with in animttla im wull ok Ihi* humiui »ulij»'ct, uiil in 
prodiicod in tlioui by faulty hy^iuue mid biitl feeding uh it iH iu the child. 
But it in u«<:dlc64 to multiply nr^utueute aj|;aLust the uutemible hji'pothcbia 
udriujcod by tliia di»tia^isiieil {uvthnlo^l. 

Still, althoujfb it cannot hn nllowntl that rickoto ia nutf^d by si.'pbUis, 
fiTphiliUc in^uitH ini\y become rickety ; tunl it in probnbl<< tbiit a parent 
wiudtuut-d by » former inpliUia muy, nithout tmusmittiut; the taint to hia 
o&priug, beget n child of (ceble constitntiou in whom ridcets can be eastly 
indiu^ed. But in both thcHc cn»eii injudicioUH feetling and intianitani' oon- 
diUons must come iuto upeintioii before the disotiae can occur. 

A pronounced tuberciibir diupositiou appLum lo have a protective power 
l^;aillMt heketii ; for altliounh weakly, jibtbiaical pnxents may give birth to 
feeble in&nta who rea^lily fall victims to rickete, it is rare to lind tho lat^ 
ter diaease iu a family where other inembei-H hi^ve died of tubercular meu- 
isgitia or other form of pure tubereulosiK — ludem. imleed. tb«^ tubcti-ciilar 
taiflchief baa occurred uecoudarUy tu rickets. Tliu reiii^oii of thii^ immunity 
mtxnH to bo that the caiuwa wiiicli are citable of setBng up rickctM vnU in- 
duce tuberculiHia in a child pi-ediNj>oaed to this form of illnetut uud very 
quickly bring Ium life to a eloee. 

How it ia thnt the»o cauaea give riae to rickets ia still undedded. It 
baa been ahown by the esperimenta of Friedlebea that a diet detieieiiL in 
pboapfaoric add anil tho lime nalta ia not capable, w was at one Uitie aup- 
poaed, of in<lucing rickot* ; indeed, it aceras probable that the essence? of 
the proocHH ia nut n mere dchcieucy of lime in the bouea, but an irritation 
<d tue bon«-inaking tissue. It ia asserted by Heitziuuu that bictic acid ex- 
ereisedOn irritating influenrM> ujion the aBt«opLaHtie tiiiuue, and that it ia 
this influence, i^ombiiicf.! with a delicienev iu lime salta, -which iudueesth© 
■liaeaae. There i» blllu doubt that luetic lu-iil is abundantly j:;*'iieni.t«d in 
tL& denmgeil digestive orgona of rickety ehihln^n, for ihiit acid hiis been 
d«te<ct«<l in tbeu- urine. If Heitxiuan's'theon,' be correct, tlio ncitl exeitea 
irritation iu the osteoplaai ic tissue, and at tbc same time dinoolves and 
helps to eliuuiiAta the calcareous matter deposited in the bonva. If, iu ad* 

<Iili<)ii, tbp sni^l>- of lime f«nlt« 1m nclitiUlf rwluootl. ricliieU U «>( np with 
still greater oortaintr. 

Morbid A ftaiomij. — In looking at a cane of well-miirked rickets the ere 
jsi At once iuTeat«(1 br tlii? ttilargenifint of the epipliysfial eiidti of tbe Ion); 
hoiiM and tbe doforniitifis of tbe Hkflptoii wljich rpniilt fmm BOfU*niDg of 
tbo OBBOoiiM fnuufwork. Li rii-ket* ihv boiii'it ore affected in Ihreo w^jH. 
Growth, althoiigli not rouiplelfely jirrwrted. '\» rHianlnl bdc) rendered 
in«f^ilnr ; o»siti>-ntinn of ptrts stiU remaining cartilacinona ia inlerferfd 
with, ruiil Ifuiiv (ihvaily ^iraified is aofteueci l^lieu a lougitudiuul svctiuu 
iH iuiu]i> of oA of tbe- long Ixmes tliv wbolc sTnicture appeiuv deeply retl- 
detic^l fmnj intense pon^ietitiou. Thu epipbyxi^ im yvry uuvfi, and the iu- 
crea»c in hizc is due cbtefl}' to an eQormous development of the cartilage, 
which is prt^pnriu}^ for the re(*eption nf the (-iLli-itreou& 8alt& The layer of 
cartilngi' into whii'li the iww bone i« ailvanring is pallwl tht zwie of raietji- 
cation. That next in owler, in whioh the c>or^>tiiwiiliir riomctitfl aimugo 
tbeiunelveH in rerliral columns in preparntiou for the ttpproacb of the 
eartliy dt-ponit. is rnll<»d iff mu'^ of ftrolifenttion. These two »}np» are 
grvAiiy tliickont^l aii<l are not wimmtod, as would be the cuee in tlie bono 
of a healthy chilil, by a ntJl-ddiiicd (^lrui{;ht hue of demarcation. In tbv 
rickety epiphysis the new bony lisnuc. in»tc!id of ailraucing bj r«siUar 
8lt.-pE Into tbe sone of calcilicatiou. uu one jx)itit being iii adTonce of an« 
other, shootH up irregnliirly, bo tbut liuea or little islets of cnlcificntioD are 
nef II far np in tlic pn>hferaliug zone, vcliilc on tlie other hand H]M>cks and 
Btrt'iikit of nnrn]('itit-< t cartilage are I<>ft fur lielow the bne of earthy dopneik 
com |)l(>t4<U* mirroiHidcd hy booe. Moreow, medulbu^' tcpaccs aif fornwd 
in iiiiiidiiAl plftccs, and appear oven in tb« proUfomting zone of oartila^ 
far in advance of the margin of ossificatiou. The cartilage cells become 
the neat of ealcareonii impreguatiou, * and are in m&nycasea converted into 
bone oorpDHolcA- Kuatl isolated masseB of lime out also often tie wen 
S(»tt«rod through the aiutris — enough in many caaea to give a dotted ap- 
pearance to a aectiuti uf the cartilage. 

CliAagE>B Bimilar to thu«ci dpHcribed in the epiphyses take pbice st tho 
enrfaoc o? tho shaft of the loo^ boDe« and in tho flat bonce. The perio&> 
teum l>oi*otaes rxttessivtly thiclt and ver}' vascular, and is connected to 
fimily «ith the tmiie beneatli that it cannot be detaobed without fragmeiita 
of the Ultor l)eing Btn]>]vd away uitb it. Its oonnective-tiosiic corjniKcles 
uudvrgo vapid prolifvratiou nud l>ecoui« tiaDaforiued dirL-ctly into bone 
ootpuwlea. The cnlcifying ]>rocc88 ia irrpgular here im it is in the cpi- 
phyaea, so tliat bty<'i4 or firm l)Ouy thtauo are iiitenowned with olhcn 
oompowd of a flbrotiH matrix containing connective tisttne or bone cor- 
poaclM mid niodulLtu-y s{Mkccii. In the flat Ihwch, espei'inlly those of the 
aknll, the irTepuhuity nitb which caknreoDS matter ih df>]iosited is well 
seen. The new porouu Imne occupies chiefly the Hurfiicc and edgeft. In 
the cnmial bones a e]»eoi*l chAn-^e i^ often ft^tmd. In certain sr>otM the 
bone bocomen pxce*iaivply thin and traiiniiarent (cniuio-tnbes). This con- 
dition is due to deficient depout of Ume aalts tu Ibv (•xtemal layen sod 
absorption of the soft tiaaae iu pUces, hero and thei-e, from the pramm of 
tbe bnuik 

Bones in whicli oniftcation ia thua ddayed and perverted are nanaltv 
soft The Kofteuing ia the onweiiaaice of tlie smaller proixirtion of earthy* 

> It ha> beca doubtvd wbatbtrr tU* «bui|:F ooenn la ti»«llli,T oMlBoatlon. iat lii tb* 
nonnKl iiruoMi thu oaldfimioH of the Inlvrmllnlu mMrlx which ■nrrauuds Ui« oanl- 
\m» mU* ij(>ncf«l« lbv> l*ttvt froin v[«w. lu ikkvtv lout ihr i-alvirviog ennolea u« 
dvpMltMl Unl b> til--' cvlla, w thu Ihu ob*»gua iu tl»tu cau he ilijtbcllj- 1 



aalta Uiey contam and the larger perceutage of orgaatc matter. Bui Uio 
dedciMK^ of lime imIIj) \h duo not to timr removal after ile|M))ntion, tiut to 
tits Btug^i«hn['<(i4wit)i whu-hllu'yare iIcikmIU^I. Thu corputiculiu'eli'itieats 
of the perioMouni are jn-wlifcriitoJ in Inv^e inmiititioH, i»ml the new matter 
is but slowly and iiii[»rfoctJT convrrteil into Ikiiip. The rm-iimft^rfnice of 
the Khaft, Hie re fore, coiimtH iii givnt. nie-ARure of hj)oit)ry UiueHic wliicli ttro 
oqIv [>iirtiiillv otc>iili<!(l. .Ul iJiia time in the iiiU^nor of rli^^ 1>niio the nonitiU 
mlAi^tncDt of Ibc iiic'IiiUiuycoiu] by absorpliou HtUl (-outinneH, t%o tliat 
RB lonp OS the ri<;kety pniceHH is active the pro]>ortioii of i>roj>ei-1y co»> 
Btructod o»ieouR matter containing ita liue jKrciaiitoge of eartliy saHa is 
cdutiuuolly iliiuiuiaiiing. Such a houc uiuHt ii«veetiiiiily he yielding And 
mibjftct to ready distortion. Thin. liowp\-er. in not the only cause of the 
booe defonoities. Affonliiiff to Strelzul!^ the oMtieoiu) trabecuUe hsTe an 
abnormal arrati^eiuent in rickety bone. Th«y ara dispotted ratlially in* 
stead of coiiceiitriivilly. He luaiutaiiia that tliia irregulahly furtlu-r di- 
minuhiMt thi*ir i)i>wer of runistanco to osieniAl preB8ur« and it) oji additional 
aouree of weakiictat. 

At the heij^lit of tlie diaeiiae the honef), besided being aoft«r, are apeci- 
fically li;;hter Uiaii natural, a&d contain an undue projxirtion of fatty 
mait^'r, Morctover, the eartilago contains a Kit'h [^M-^n'ttnta)^ of water. 
Th<' boae on imidysus baa b««Q skonn to conHist of 33 to 52 per coat, of 
pnrthr solta. iuHteai^ of >'>;) to 65 as in health, atid ita tuiimal matter ia naid 
Ui yield no gelatine on boilin)^. 

When the (iisease iwoDitiea arreated, cut^iticntion in th© aoft, newly 
fo^lUl^l tissue ttikvn pliiL-c rapidly. The louev spongy utructure cloBfB up 
and bocomc» thick and linnh and the whole bone is heavy and dense. 

The inorbid cJuuigoH in the oHseuus in'stem form, no doubt, the moat 
«tuuacteri3tic feature of the rickety state : but rickets in aot merely n dia- 
caae of the bone«. In ndditiou. mnuus piitholoj^tMil ohmigca are di^'uvered 
in the bodtea of children who liave died while Kufferiuj; troui tbia affection. 
. La some the liTer, spleen, and li-mphatic glands are found diseased, th« 
■nuacular atructure ia altereil in Iiail (-lutett, the braiti m^y be affected, and 
the urine almost invariably exIiibitK jmthological charact«r& 

Thf- altemtioufl in the liver, mpleou, and .lymphatic glands axe by so 
mcatiH present in erery caae. or even iu evetr marked case of the disenaei 
The ofTec-lcd oi-j;iuih are enlnrK^od, tough, and Holid to the touch, and hfvavy 
out of projMirtion to their s.'u.e. 'Vhe clinnge in usually most marked iii the 
spleen. J3r. DiekiuDon coninders it to bo due to no "new growth or infil- 
trated dci>osi(." hut to a hypurplaain o£ the normal tissue of tJie organ, and 
chiedy of the interstitial couaecLiTe tiiunie. The fibroUR and epithelial ele- 
meuta are hypertrophted, and at the same time their earthy taiHa are de- 
ficient in tjuantity. Iu the liver Uie fibroid sliuuth within tho smaller portal 
canals is twim it^ uatuntl sire, luid in 1 he ghinilular atnicture the yetlonitih 
Kdiu are boiuidwl by a thui piukiHh or gmyish fine, bi the «/i/f(?ij Uie in- 
lentitial cxmnectJTe Urnue way become ao hyiKTlixipliied that the trabecnln 
■re as tliirk sa the epoces they enclose. Iu tJie nivahcs the corpuaelea are 
■eeit by the micnwcope to be crtiwdetl together. The organ U hard and 
rivutant, M> that it eau be cut with the utmost eaae into thin oectioua. Its 
uirfare in deep red or purple in colour, witli aiiiootli white spotn from en- 
large'] >lHlpighi.Tn rorpiisiueii. It* Hection i« deep red uiotUed with pale 
buff colour. But httlo blood can he M(juM'»>iI from the cut tmrface, Tlie 
tymijftatu' glamla arc »omfitimc4) oiso vularged and hanl. They ai-e white 
and opaque uu section from accumuliitioii u( their eelhilar contents. 

Enlargement uf the liver in rioketuis not always the cooseijueneo nf the 





pAlUologteol condiUon tleocribed. If a rii>!)cely cbikl lie niOf^h Trasted from 
iutratinal catarrh or other digeetire troaUle. the liver mav W BWdUt-ii frum 
fsU^ ittfiltnitioD. If he hav« b«6n 8u1>)ert to r6)Mtate(l ]»ilt[)ouar>' rit.-uTh)i 
witu gnst interference with t)i« resi>initorT ftuirtimi, tli« oryta\ may lie 
«alargod froio ohrouic oougcsiiou. so aJeo tur^escvDce of ihv bi>U'eii luaj 
be tonuiX uimcroaiptuiietl biruijr afiprecuible lestou of tUeliverorlv'"!'^^^*^ 
gliuiilH. Ill Kline Pfte«8 the incrraM in uko of llic org-m njipi-nrK to bi.' (Iui<, 
M iu the ctuid of the liver, to n rliroQio oongMtive proc«w frhich causes a 
lar^« (IfTulopuieut of hrnJitie fihruiil ninteri^ In otliers the spleeD seems 
to be the aent merely of siiiiiile^ hrperpWin aiid preaetita tbe ordiniu'j;' 
chnniRteni of hx'jx'rlroiiiiy, Rupb as ilfr Bctcm iii nomn cjixcr of inborited irq>li- 
ilia and it) th« ^uv cm-liexla. Tliiit form of enlargenuiDt is rcfDrreil to 
elsewberc (nee p«ge 23H). 

The luuscles have been noticed hy Ha William Jenner to t>o muaU. |Ndr. 
dabbv, and soft Their tibri-s uaJcr the niicrotK-o[if are softvr imd (ulcr 
tliaii iiiitunil. with the tttriui very in<listiuctly markrti. Tht- brain is ttcaae- 
tiiiieu siunll iind dliniDkeu, k>j that lluid is thruuii uiit tu till up the ^jmoe 
left vncniit in tlie skull cavity. It in nl90 muwetitutM eiiliirKed, bo much bo, 
in some cases, as to oiuae distention ol the orauitiin. r>r. Hilton Fni;;^' has 
n-fcrred to a ciise which waa tafceo to be on« of lulvauceil liyilrorL'pbalns 
until au exniiiiiiiitioti of the body nfter death ^owt-d that tlio bruin 611«d 
Dp the cranial ciivity completely. Iu sach cosca the orison, although en- 
larged, has n liefJthy appeaianceand in of natimd consiHtenre. The liyj^er- 
trophy in said to be in the nearoglia without any iocrease in the nVrve- 

The urino nontainti on incrooiutd proportion of pboHplinto of lime, and 
lactic ucid lino been foim«l in it by ooiiie obsenerK The Hecretiou ia pale 
in colour and often dr]>oiiit« crystoln of oxalate of lime. Often, nlao, as ia 
DO commonly the ciisu in (-liilvlrDU in whuin ucid is Urgflv ^■ufjutcd from 
fermentafioD of food, cryHtnU of uric- add nud even coiuiidcnible quantities' 
of red Hniid mny be passed from the kiduevH. 

In addition to the above |Mth(>Ioe;ical conditiona, vludi may be eon- 
(iidrn-il lo nrin.- directly from the (^ciiem) disease, there are others wliidt 
Diny be luuki-d upon as iiccidentiil xiucv they are in<liic«^d mechHuically by 
the dcformitieK of the thorax resiiltinfi from the 8oft«'nin|; of the ribs, hi 
otlcatteti of diHtoi'tion of the friuucwork of the chest two piilmonaiy lesioiia 
are invjiriahly present. Theutt ajc ^'iiipIiyHeraa and rollspse. Tlie t^iiiphy- 
ftenin is M-iitf) ut i.\u: luiteriiir )i<it-itci-vi ot the lun^ti, nnd e\t«in(lit Inicknarda 
for iiboiil, tiuTei|niu-terb of lui iiit-b from their frtv luartfinK. InitociUidely 
outsitle this line of ililnted liui;: liasiie is a Unc of coILip«e which separates 
it from the healtJiy pilnionury KubBtance beyond. TheHe leaionH occur to- 
gether and, fdlhon^h not dependent one upon another, are pi-oduced br 
the HUtnL- mecluinicid lueaniK. During the aat of iuHpinitiou the noftenecl 
ribti sink in, and the jjrt'Miire of the enlarged ends of the rilia r rnnpnwtB 
the lung tianuo with u'liicli they are in contact so an to prerent its expan- 
BMQ b}' the air which inQates the reuiaiuder of the luug. While, however, 
tlie diiimettrof the chest is narrowed kterally, its anlero-poMlerior diameter 
la iucreaMd by tlie pi-otrusion of the atoninm. Coiiaei]iieiit]y the alveoh 
of tJie anterior boi-dera, iuiin*Hliat«Iy boliirid tho l'reii>:t-bone, are dia- 
tetided by the air whidi is forccil into tbia port to till tip tlie resulting 

Polmooiiry collapse is not always lituited to the partB of the luDf; cor- 
raapondiut,' to the en<U ol the riba. Tliere in often to be Heeu. iu addition, 
a certain amount of oteJectania at the ItOMea of the Kuigs behind. CoUapM 



at thin part of the lung ia due to pnhnonitrv catjurh and plugging of nn 
air-tu[M> with mucus. Ita mechmiUiiii is ilettrribed elsewhori^ (fma i*. 1G6). 

Tliv i.'iiUr|;oJ c-pipLjtK-s vi tlic rib», bcitiUcs thoir effect upon iLe lung 
tusue. asv ulau tliL- L-auso of the piitrhcH of ciiTtinnKTrihAd upiicit)' Hticu uti 
tlie viscenil Hurfat-e of the pehcardiuiu aud au the Bpleeu. That on tlie 
iK,Ti<:»rdium is 3Jtiiftt«(l on tae left reiitricle a httle aboT« the apex of the 
Ju-art At this point, the b««rt al each beat ooniee into contact with 
the Dodule of the tifih rib. That uu the q>leeii is pitxluL-ed iu the name 
vfoy bv attrition, the orgiiti vm it rises uti<l falls tii reHpinitiou boiug 
rubbea against a similar I'ostnl projection. In each case the white |mioh ia 
limitc<l to the fibrotttt lar^r. 

From fl cousiil^ratiou of the morbid changes iiscovarod in Ihnbodiea 
of rickety children, it is e^•ident that the di»oase is a Tcry spoftial one, ii>- 
\olving very wiile-ttprea*^! lesions of xtrurture. Attention has latelj been 
dtrcetecl to the whoU? «ubj«irt of bone changes in the voung subject, and 
it ia Mecrto<l that nmny oa;*«s in c-iiich boiw; softening has br^en pronounced 
lire not real cxamph-a of rickcta, but ought riitliL-r to fall uuiicr Uie hctuU 
ing of anteo-iiiiilacia : tlie oshcouh <'liangeH resembling closelv Uiuae olwerr- 
nbie in tiaaes of osteo-malacis in the mhilt. T}ic ijiiestion is of iiiinortance, 
for the pathology of the tno conthtions iu e.-«tetitiiilly dinnimilm-, In O6t«o> 
cia »oftei]iiiif itt thu coiiw.-(iucnce of u remoTal of the cnrthy coni^titu- 
:U from jwrfectly fomiml boue. In rickets owiificatian is iucoiiiplet©, 
and much new material is thrown out vrliich undergoes very imperfect 
rakiticdtion. The <iuca1ioii can only ho ik-cidtxl by a careful tttuity of the 
morbid appcsuranw*. In Uie case of a rickety Uttle girl, ngad eighteen 
mooths, ui^Hcribed by Dr. Kehn of Frankfort, there was marked diittortitni 
aad aoft«aiag of many of the loni; b^ties. with otli«r rigus usually consid- 
ered charaeteristie of rickets. Thfl diseaoe. however, watt jiidfrwl to l»e 
oatoo-maJocia on Iho ground that although itofteuiug wa« a iuH.rked feuture 
in tlio boDM^ tbe opipbyaeol cud» were only moderately awoUen, and in 
the boncH of the lower extremitic» were haixlly i^wnllen at all Morc-ot'er, 
the whole skeleton was etcetwively thin and the lower extremities were 
quite straight. * There was, hnwcvor, n considerable formation of soft peri- 
osteal deposit ; luid a rickety element in the case was admitted. It is pos- 
sible that true onteo-maliu'iu may I>e grafteil nn a case of ricketfi. ok is 
mipiioscd by Dr. Rehu to have happened in the instance n-fdrred to, but 
further obaormtioua are to he deairod before any (lefiuite coucluwon in 
the matter can he arrived at. 

Befon- cloeing thf subject of the patholoCT of rickets a few wordfl ma^ 
bo said with regu^l to the aises of flo-called " congenital ricketa." This 
term in applied to a condition in wLich the limba of a new-born child are 
found to present peculiar chamdent. The shafts of the bunee are short 
and thickened, and may be found bent or even broken. At the eanie time 
the epiphyMti are swollen, soft, and quite cart ilaginoiia The (x>n<lition, 
hnweVE-r. ditfere nmterially from true rickets, and has* l>**n oompared by 
Kbertb to tlmt found in cretinoid chiMreu. In all recorded casea where 
th«r futft-moHtrtn n|>[H.-iintnccis have been noted the shaftH of the bouee 
bitve been found much osaific*! and remarkably thick and stunted. This 
peculiarity gives, of coume, a curimis ahortQe»i to the limba. ' The dia- 
phjvea, iostesd of being imperfectly onnfied lu in rickets, vith great 
pofoeity of the medullary parts of tlie bone and thickneoa oi the perioe- 

' tn a DSM desoribed tgr Dr. Barlow thv upper limbs reached onlj to the umbllt 
cm, aad tbr town- vxtmaitlw atensarrd no more ilian Are Inchea la l«Dgth. 



teum, ftre esc«efflT«ly bard uu<I compact. Fibmas tisBU* dmved from tho 
inferior Iitjem of tbe penoateum intrudes botwoon tlio cpipbvsb aud Lhe 
Mbaft, Tlie epiphyses, also, are enliuyeid geucraUy luid not uulyat the line 
of ctildtiatLion, an in rickottt ; and their mirmwopical chnrac'ters ]irf"«>ut 
seiifiible differ«ticca. lu a caso n'cortlc-.I hy I'rttil the uu'tiUge ceWa in tb« 
epijibysee were found lyinj; confusttU^ Uij;HUii-r. A» tbey aupnMcheti Uie 
■linpbysU tbey were seen tu become tliiller, e)i]>»>).-iaUy iu tue jieripbtTnl 
]>oi'>ioiis, and finally pwM*! inU> th^ lavcr »( oonuoctivc tinsue which mp' 
Krated ibtt (^eatcr port of the opipbysiu frwiti tlit Bhitfl of the boue. The 
reaemblance between tliew? ca»«K and cmtiaisiii is displiiyed no! only by 
the stunting and timi ustdliL'atiMii of tbe diapbyse^. There is the wime 
teDdimcy to i?ui'ly union by ossification of the l>aai-occipital and poxt- 
mlienuidal buncs. Some sptteiineua of "cou^^-uital rickets " prettiTvcd in. 
tlte Museum uf the Koyal College uf 8urgeouti exhibit tliio peculiarity, 
and in others, where the soft parte remain intact, many of tbe facial chu^ 
actf mtiuj uf the cretin are abo to be observed. 

St/uiptonis. — Ah ruiirlit bo es^wcted in a diseawt vliicb ariB«B as a direct 
oonBequence of fiudty nutrition, the ^mptonts propOT to rtckotx are usa- 
lUly preoedeil hy othera indicAtinfr a general interference with the DUtritive 
proeetuea. Digestive tlerangementH are common, but theM eomponitiTely 
seldom consist in attacks of severe or r<^pcated vomiting nr dLarnia«. Id 
mcttt caua tbo demngctQcxit is limited to a Icsseninf! of digeetire ]>nwcr, so 
that the motionii, without being arlusUy loose, are more frequent than 
naturuL They are large, pasty-Ionking, and ofieiisiTc from the 4jumitity of 
ferinaccoua and ouixly matters which are pn-tRiiig timligested out of tbo 
body. At thin time Uic child is often initiiblv and fn:LfuL Hin belly may 
be awollen fn)m flatuleut disiteutioii. and be frequently crie»t with paiua 
in the abilonieti. For this reafiun he may be often found aaloep in hia cot 
resting ou hia uIichI, or ftupported on his kuecs and elbows with hit* head 
buried in the pillow. TIic tiriuo it* often very acid aud caueea UDfattineaa 
in luieturitiun. If the uhild jierspireM eupiouely the i-euul Beoretiou may 
contain oonMderable t^uantiticH of uric ncid sand. 

Unless by jiidiciout^ trcatmeut nml diet the alimentary r&nal lie rcsbn^ 
to a liB.'Ulhy ulate the child, although often slill plump to the eye, Wcomes 
pale and flabby. Tlien, after an int<^n-al wliti^hvoi-ios in durnliou aeeoi-ding 
to thu natural strength of the patient and the woi'v or lesa wholdjouienesa 
of Ids Kiirroiuidinga, the early symptoms are noticed Tbe onset of the 
disease is mmomiced by tliree speuia! sj-mptomH, The child begins to 
sweat about the bead uikI mx'k ; he thrown ofl' hiA coverings at night taul 
lies naked iu his cot ; and begins shortly afterwards to exhibit uneanuiesa 
if much danciHl about in hii« nurse 'x arm»< or handleil without the utmost 

The Bweatinp: in proftise and oocura principaQy during deep. At niglii 
beada of moisture may he seen standing oD nis brow^ and tbe sweat 
trickleR off his he»ul on to the pillow, which 'n often saturated by the seere- 
tion. If the child fall fwlcep in the dny-tiine, or even if he eiert bimstJf 
much while uwoke, tlie same phenomenon may he noticed. The irritation 
of this i>enipuation often gives rise lo a crop of miliaria about the neck, 
behind t!io eaiv, and ou the forehead. The supei-ticiid veins of tbe temples 
tOK full, the jugulai- veins are unusaally visible, imd the carotid arteries 
may be felt to puUnt<^ slivngly. 

Tbe desire of tbe child to lie cool at night comes on almost at tbo same 
time with tbe preceding, and may be obser^-ed in the coldvot ^veuthcr. It 
is, in«]eed, a firoquout cbum of catarrh in tbeee poiienbi, and I have seen 


nianr cnaea in vbich contitined loonenesH of the bowels was flppni'eiitly 
luuiutained hv repeatec3 chills no coiilrftcteJ. For the samo reuKOii a ire- 
qnent con^li from pulmonnrv ciLtArrh is n eommon syiuptom. 

Oeneral tcudc-riicjot umiUly bc^HDX to be Qoticetl tit a certain intervnl 
after the two othir ii>iii]»tmn« whirh Imve been meiitionEHl. It is »))<itni by 
uattsua] Miuutivenesa Ui even Kligtit pr(>»iure, ntid ftppenrs to lie neutrd in 
Uio muscle* tta well as the bouce. Tlie ohlM cri<.*« if liftv^l ii]> ut all 
abmptlr or nubji-cteJ to riiiy jolt, or jnr, iirnl jm-fcn* to lie i|i)ietl^' iu liis 
cot or on tliu Ltjj of Inn uiirse. This K\iiij)tom »eliIoin oociira iiutil tlio 
osseous chaDj*e3 ^ev well niarked. It is aCL-onipntiied by luieAiuDPtM of 
pain about the liemi, which is indicAteil by a inonotoiions iaoTent«nt of the 
hnA from a<1v to »i(le iipou the pillow. The bair covering the nccJinit is 
often worn nwny liy l-hiu coiiHtaut luovt'iiic-iit., and tJie bfmuom of tti« ^»ck 
of the af:ilp from this caana is a very (■haravictisiic- F^nptom. Toudmioss 
is not nlwnys notict^tl. It is uniialtv (■oiitiiicil to cnses where tlte diseaae in 
soTere. In tbo iiiil<l <!a.'ift!i, whidi are shown laerrly by n flight. fiiitorgO' 
xneut o( tb« wvist* (uid (uiklw, without any apparent softening of the bonts, 
tlie Bymptnm is usually abssnL 

l^e Imne <:bftngeK oonsUt hi an <tnliirf^nu>nt of tlie epipbyseal euds of 
tbfl loiJ^ Itonos, in athickeniiij; of tho lliit bones, and iu a general softening 
of nlL 'Shu ciil(tr;,'ciuvut of tlio rndti of tho bont.'S oocupivti the )>oint of 
junction of thu sliafl with the i^pipbysia. Both pxtremiliiis of the bouo uiny 
suffer, but the t'haiij;e is niituntlly moat ob\ious in the pnrt wliieh is jiear- 
est to the surface. The rilst at their Btcnial cmls are u-sually the tirat to b« 
affect«<l ; thtin the boues of the wrists. Ajt a rule. Lhu 4-piph,v»ciiI su-elliuK 
is tooie murked iu tlio bonett of tbu tippur (•xtreuiitii'K tbuu it is in tht>se 
of the lower. The thickoning of the tUt bones is well seen in the bonoB of 
Uie cniuiuiu, au<l the softening nf uU the Ixiues is one of the causefl of the 
defonnities of the trunk nnd Hnilis which are no <^'ommuu in Muly htv. It 
must not, howi-vor. bo «iiippo»i}(1 that even,- eni4i' of rickets entU in liolteuiug 
oQiI tlistortiou. All du^irees of ssverity of tho diiiraae mar be met with, 
uul in mild caaes softening and the conae<]aont deformities of bone are 
entirely abspnt F!ven in more sevnre eases we must not expect in every 
inata&«« to And al) the svmptoius to bo OQumorated. Iu one chiki tho 
cpij^yaool swvUingB attract mont attention ; in another tlie softening oF 
the bones. In sonio the chest is esceBsirely distorted and Uie bones 
of the limbs ore eoiiiparativoly straight In otbei-s the limba arc greatly 
twisted while the Ihurax ia but littlo altered from the uonnid sha]>u. These 
dilTereaoeM ure wud 1>y Bugin^ky to be detfrmined by the part uf the 
skeleton in which growth iiii]}|>ens to be most st'tive at the time of the 

En a pronounced case of rickets the effect of the bone lesions is very 
■trikiDg and poeulinr : 

The diiiii is large with a long nntera-posterior diatneter, and often, on 
Bcoount of Uie comparatively small mze of the face, looks larger than it 
really ia. Tlie forehead in si|uare from exagijen^tinn of the bosses of tJie 
frontal bones, and is 8om«>tiinc'S vnvy prominent fif>m tlie development in 
Um boDv of cellular cavitlcH. The foutuncUo is kirge oud rcmuius open 
lont; after the eml of tlie second year. Sometimeti, if the size of the brain 
increased, or tliere is exensa of fluid in tJie skull cavity, the sutures in 
'*oftl»ection with the fontimelle can be felt to be more or less distinctly 
gftping. On ouxiunt of tht^ thit-keiiiiig of the edges of the tint liones the 
margins of th« sutures and fontaDolk' uru elenited. ho thiit the latter feel 
;1 and the sutures are indicated by furrows. Tho posti'rior foa- 


! m 





tiinellQ fans nsuaDf dinppoir^ bi>fnrf> the hoginiiinp of tl)« Ulii«8S, but in 
extreme caaeB. wbere tlic <li>w-ii»e bt-gini eorty luiil tlie svmptoms ore pro- 
nouiic«4l, it nmy hv f«l( to tw titill uudoMil. 

In ererv chho of rickets lli<> conUitiuu kuowD fls " (•nuiio-tabeK " and 
dpHcriboil hy ElaaBeer should be seai'cbed for. It i« bewt detected by 
preaain;; gently -witli ihe tipe of tlie Rn^eFS on tlie ixiatcrior Biirface of the 
haul. If cninio-tabea bo pretwnt, Kpots vill Iw f«lt where tlie \tOQ6 U thin, 
soft, and «lfu<tic, as if nt tliix point it had been ccaiTorted into tightly 
Btrtitcticd pardunent The sputH arr eeldou larger than the diamvtvr of a 
^ood-Bized pea, and aie tuniiulr roufinc>d to tbe occipital bone. Tliey are 
esusad by abnuptioo of the itnporfeclly cMoofifd )>oni> from its comprf-imiou 
lM>tw««n the pLUov and the bniu na tl)« child lii-8 in his cot. Thvv uiity 
\m- ii]ct with as notju iM the third month of Ufi;. and iiru Nud to be tLc cur- 
Yivnt nif^ of thv diist'iLHc. 

A nck^ty cliild'e hair ia nsually thin, and id often kept moiid. by the 
copious [jfmpirattoDs to wliidi the bead ia Huhjet't whtmever Ihe (mtient 
faU.« nnK'i-[i. Ill iiwi^t ric-kety i>liil<lit'U n Hyxtolic iimnmir of variable inten- 
ftity r*ati bo lie»nl with the etftLoi!co]>6 appli<>d oxer lh« fontanelle. Ao- 
cordinp to Scuiitor. the Eynijitom merely Khow« that an osaified uembmne 
IH better fitted ihiui tlie n-nnial boneit to Iraiittmit to tlie ear a)und«(:mer- 
at«d in the cerebml vesselfi. Therc^ in no doubt tlint it ia rarely henrd in 
ehildien iti whom tlie foutaneU« lnu) rloMxl. The murmur ifi Rometimcs 
curiouidy loiwL Nut lonj,' afio n nidlid. flabby little girl, between two and 
tlinw yeini old. the subject of rickets, was brought to me from the coun- 
try on a«couiit of n stranpf noiaf which was heard at times to proceed 
from her head. Tho child lind cut rdl her teetli, hut was vfty weak ou her 
li^^rR. She watt itiibject to attacks of xtridulmw laryngitis. Tlte foutauello 
U'Wt nut quit« oloBciI. Her he<irt a»d lunga were healthy. It was Haid 
th^it in this child a noise like " the pumng of a kitten," not continuous, 
hut. dihtiiictly itilcniiitt^nt^ "like a pulsation." could l>e heard at timee. It 
wag loudest at the ri^bt xtile of the lueatl. It was not exj^ciaUy loud after 
•xertion, and waa only occuRioiially nu<Iible. It wax hronl beat iiumedi- 
atdy the child iiwnke in the moruing. and waK tlicu distinctly penrcptible 
iMTend jTirds from her cot Durinf* the child b ATjtil to nic no ceirbral or 
other iniuTuur eould Ims heard willi tbe Ktetbot^'ope. Still, I bad no reosDU 
to doabt the good faith of tlie relativee. The mother, who gave me th« 
account, told her tale in a stnightiorward manner, witli the air of one who 
WW eager to I'eceive an explanation of a myster}' which had pUKzled her 
and made bor anxious 

The cliief cuuw of the tunollucHB of the face is the imperfect develop- 
ment of the jnwjL Flcisclimann has drawn attention to the anRidaritv, and 
flatnoBs anteriorly, of the Ifiwor jaw. It has lost its normal curve, liie in- 
dsors are qtiitc in n Rtrai^'ht line ; then at the situation of the eye-tcotb tha 
inw forms n sAmrp aui^lc- and beudn abruptly backwards. Tliia in duo to 
imperfect growth of the middle piHJoii of Iht^ jaw. Ba^iiuaky describes in 
nddilion an occasional want of aymmclry between the two halves of the 
\}one, which jn^vcs the aptioanuice of one side being higher than the other. 
The effect of Ihis dcliircd dc^■eklpmc□^ of the jaw upon dentition ia very 
important Rickety children are late in teething. At whatever age be- 
fore the completion of dentition the disease may begin, directly the cnutial 
or Caciul bones become tLffectcd there is complete arrt^t in dental develop- 
ment. Tims, if the di^^eaw occiut* before any teeth Iwve l>een cut, their 
appi>aranc« may be indclinitely delayed. If aeveral teeth have already 
pierced the (pun the procesa stops there, and months may elapec beforo 




filCKKTS — 8T MTT0M9 . 

otlietD ar*" seen. Wlicn. liowever. tip t«fitli do come they are imtiaily i-iit 
wit.liout iniioli Iroiiblo ; but tbcy an^ in inoxt tmeoa of 1uu1 qtuiLity from im- 
perfect Jcvekipiaeut of the <l«utal vniiiucl, oud quickly blockra un<l decay. 

Thf t^rrst u <l«forinf<l in » very chiiracterislid maimer on account of the 
inability of the softened ribs to resist llir pr^Rsiire of the atmoKjihcni. 
Under DortHfU conditiotui. when the libs rise and the chf^st ciponde in Uie 
set of iuspirution, tli« i^alid fmmuwork of tht.' tiiiimx i» u1>tc 1o withHUuid 
the presisurt* of tlie pxjiii^d air, and tbc rbrtit ennilv eoliirf^es tu idlow of 
inflatiOD of the lungs. Air rusdife throuph Mie wunl-pipt? U> dil&t« thp 
piiltnoiiarr tinsue in projtortion as the cli««t-walU evpAiiu. lu ttit- rickety 
<-lu'Ht. on Uie contrary, tlie ribe ore not firm but yii.*lding. Cunseqaeutly 
the fmiiiework of tlio thorax is not ri^fid euo*i^1i to resist th*' i>reH- 
Bitiv of the ttir from without, and when the cflbi-t ia made to expand the 
chent the Hoftnned rilw are forced in at the nUlan — the parts where they 
mn* knrt Rup|>orted. This sinkinj^ in of thrr ribM throws tli<« sleruiini for- 
wards. We thoii'fom ftn<l tlie chi'Ht ginnwi Ifitcmlly and tho brwwt-lKvao 
pminiucnt and chiirp. The proovo is lirnnd iind Hiiallnw, and rtmrbcH from 
the »e«>iid or thinl rib to the hyptwhoiidriuni. Tlie bottom of the depres- 
ia formed bv th« ribs out.tide Ibeir jimotion with tb(> cnr+iJiipwi. 
■fete aloDg tJie inuer side of tlic f^nxiovu tlie mvoUirn eudu of the rib« 
flib) be seen, lookiu{; like a row of liu^c bi^da under the skin. 'Vhv ^oove 
is doepOBt ID children who Lave HuGered uiiieb from pulmonary' ratiinh. 
In such subjert* the inip«^linieiit to the entram-e of aiv, alretuiy existing, 
is increased by the narrowing in the calibre of tlie siualler tulntH ijidiicect 
by the demngement ; and th» softened ribK receive si ill \vm* support, from 
the lUDg tiaeue beaenth them. In ii {.'beet su deformed eai-h iiiiipimtjou 
inOTMBW the depth of the Literal cmoTP. and at the tauue tiiiio protluvL-s a 
deep finTOW which pmatteH liorizonfally utiyish the rhpsl. at the Itvel of tlie 
epigBBtrium. Thit* formwinf; of the aiirfiir-e bru* heon hIiouii by Hir Wil- 
htan -lenner to bo duo not to the traction of the dinphtn^i, ns vran taught 
by Rjkibuisky, but like the lalfral proo^*"'* of *he chest lo utmoM|difric 
presKure. The liver, Htomaeh, and spleen nuppart the parietes under 
which they tie, and prevent the wall at thnse points from fnllinp in. 

The fpuff is oft^ l>eut. Li nu infant thu cervical curve is iucrooaed 
so that, the head h siipporl»1 witli dittictdty and fsllx biK-kmu^U upon the 
riloulderi; producing n ver^- eharurrteristic attitude. Also, the woi^ht nf 
tiie bwd KDd shoulders, as the cMld sits bending forwaj-da, cau!!0)i n pro- 
jection backwards of the doixal an<l lumbar spines, which in sometimeH no 
Aarp IM to give the appearance of vertebral e/iries. The tlefonuitj', how- 
•fmr, RUlwidnR compl^'toly wh^n tho child in t*i.ken up nnil(>t' th<i arms and 
the HpiDc is drawii upon by tht> weight of the limbti lujd jM'lviH. If the pa- 
tient is able to walk, there is an increase in tlie hmibnr and dur*J curves. 
Tlw* furvattii-e may Ite lateral. If tlift chibi ia carried habitually on his 
QUtwe's left arm, tht^ trunk av.ay9 vwi to the rij^ht ; if on the right arm, 
the body Imuih to the left In all these cases the deformity is due to waiL- 
nesH of tha ligainents and musclea 

The bouee forming the txflvii may be alao defonaed, and eotnetimofl, 
like the ebest, ore greatly timtortei]. The shape assumecl by thia frame- 
work i» eery TariouK for lui it in due in all awim to comprewiian of the 
yielding bones, it will lie detemuned partly by the age at which tlie dis> 
eue bef[itka, and the detn'ee to which ossificatioa has advanced. It ia 
tbsrefora different, aocortling to the usual attitude of the child, imd to the 
eiRm(P4l«]ie« of his Iwinj: able or not to walk about Ita most ordinary 
lihw>a S aa irTtt]?ular thangle. Di«torti(«Q of the pelvis is of great impor- 

i>isEASR rs cnn-DREN. 

tniire in ittt Liillii«iicft upon cJiiltLliraring in fhe mlult femnle ; but *mvn in 
early lifi- it riiny hnxf (p^ivn oonw^iiitMiftOR. Tlic i)]M-ra1iDii of litlKitotnjr in 
Lbe yuiiD;; mibjt-ct hat bcvii attvuilcd with Kcnoti? itifficultiw. tiu«1 ovea 
bet!U fullonetl by fatal remills on nccoiint of tliiii dcfunuity. 

Ill the 1)uti«8 of the !tmfin tlie articailar tnils are nodular from mi* 
largemont, but the shafts tbi>iii»«lTf?R Iidto oHen ui niiaitunil sb^pp. In 
the Ami (he /lumcrtif m ufu-u cuni-vl M Uw- iufwrtion of tbe lifltoitl muscV 
by tb« vi-iglit of tli<^ foreHriii and luuid wb«ii the iinu ie ntitu-d. Tlia ra> 
diuif and ultta aro nirred outwiuv^lu and tnistad, for a riokt'ly obild often 
reata hia baudti tm th^ l^ed or lluor to mmA liis f4«ble tniinf: in tnipportiug 
the w^-ight of bit* tniiik. In tht' /rmur tlie licnd of tbe Ijodo may be bfiut 
at on niiglo with the shufL TIh- budy of th« bono \» carved fnrvardB if 
the cliild vAimot walk ; for aa he aits ou h'w raoUior's Up tlie wcigbt of ttM 
It's drng)4 11(1011 tlie \ovivr jNurt of tbe tliigh. If hr nin n-alk, lb« <*arv« iai 
iin extti^jionUiiin of tlio mitiitnl curve — fom'ardH iind outwards. Tbe tiMa 
is curvfld outwards jf tho ehild is tma1>le to »-idi. so that when the {Mtient 
ia belfl upri^jUb the knees are wiilely apart. Tho di;funuily )» due in tiis 
case to tue ixinition commonly asmuued by Hit uifcint. who in adilictal to 
sitting ci-oHB-leggecl nu hia l»d, ao aK to make preiisiu-e upon tho ouuijle of 
bis auklt. lu chikireii who cAu walk au fihrupt curve, having its t-ODTexity 
furwapls ruid outniinls. in swu in the lower thiixi of the Iwiie. The Iowit 
liiiilw are not diatortfd iu the infant to tr>M\ufni\y an ti)f anna. If the 
child fjvnnot stjuid, thewe ^xtromitics, nlthonph «inall and f<«blp, iine uftea 
pirfoctly straiciht In caseH nhpre Ihc defonnity of the Ions boues i» t-x- 
treme, the aliaft ia not only lieut but broken, for a parliul (■■Krw.-n-slii-k") 
frsfture ia gencndly jiirapnt. ITie rajne tiling is often Keen in tbe ebiviclea 
which have their iiormid curvt-.i very jjiiatly exR^enU«d. 

[lenidcrt Ihv Buflt-riiii>; luid duforuiity of tlie bones there ia luiollier oou- 
ae(pienf-e of thu diKftMC which in of •^mal inipdrlAUce. Tbitt is tli* UTMtj 
of grou-th tiud devchtpmont of bone which <-u]i b« noticed in <dl cases oil 
Hcf-ori: rickets. Rickety cbildreji arc short for their a^e, and remun under- 
sized after the ditteaiM-' lina passed away. The arreiit of growtb is moat 
marked in the bones of the jaws, of the Iowpj- limbs, and of tbe pelvis. As 
it nffc-ets the pel^ns. this featni^e ia of oapenial iinportAnec on neeount of its 
inftuenee iiiion ptirtnritiou in after life; for if tht capacity of the pelvic 
frnruework be not only diininishinl by distortion, bnt also r«lati\ely Minnll 
from nrrestt of development and growth, ihi^i difhcultiea in the way of aoo-j 
ccssful di'livery may Im- insitporablc 

Thu wcakncsia in the lower Hmba. which ia a mnrke<l feature in rickeU, 
is due not tdone tu (eeblenesM of the muscles combiiied with the ganeml 
debility of tbe child. There is also great weoknem aud IcKieonew of tfaa 
liguiueitt« of the joiuta. Tliia weaknetis is more pronounced in cfUMM where 
the diiiensc begins after tbe end of the second yi^ar. In such osee of lata 
rickets scjftening and deformity of Itnne are lees common features of tbe 
disease, while the looueness of tlic joints from okarked relaxatioo of tb4 
liguinciilH may nach n \<tiy high tlegiic. In such cases, too, the 
huvin(j Ih'i^uu after tho completion of dentition, tho teeth are ofl«Q whitA^^ 
aud sound. 

During the pi-ogrees of the bone-ehnngee which have been described, 
the general (^biuitlDUis continue imd beeonic motT severe. The head per- 
KpiratioiiH are prufuiw : the child can hAnlly be kept covered in bis Iwl, 
but whether it be night or day pushes off the bed-clothea and cxposetf hin 
naked limba to the air. In bad cjises hia tenderuesa au<l dislike to movo- 
ment ore extreme. So long as he is left ulone he is patient aud atiU, but 

itppmAched or notiood Iw at onre bMOin^H fretful and ftpprehensiTe 
of (lirturiKiuco. Ho will ait (or hoiire toRetJiei-. lietitUftis of hin to\-s, 
cnjiiclitxl up ill LU cot : Uis legs doubled lM>iienl.)i liim, his spine bovred, 
Bud bin b»<fid tbrtiwii badt ; aupporting hin body upcm bix hmuls ]>lace<l be- 
fore Uim ou tbe bed. On amsoiint of tbt> anfUnPfi ribn uad. Iits «oaeequ«iLt 
<liaicultv in e&jxuKliu^' Uj« lungs, hix bntttbitit,'- is rapiiL iwil bia wbole nt- 
tentiuD Mceuis eouctiDliiitf^l upon \hv efficient diHctuirge of tbin function. 
His ippetite t&tim). Sometiiuea it is poor, but more often it a good imd 
BMy be ravenous. If attention bas col Ijeeii pikid to Lix (li«t. «Bd tlio child 
coDtiriiieit to pans Inr^c ijiianlitiat uf i>altt, ])titiy-likp loaltcr, he will luually 
KWidluw idru<j»it nurtliiug tlial 't» giwu U) hiiu. SirkueHH in not couinioi^ 
and Berer^ diarrbo-a is only occosiouAll; met with ; but tuod«rot« attacks of 
pQiving arf fr«ipienUy Hefii. the Rtools beings green, nUtuy, and oflenttire. 

Til* l>*lly ill rirki'ty obilitreii i« alwayn larRe. e»'eii iu <•»!**« where no dis- 
MM of tbe livfr or upleen cnn bo doteotei). The swoiliii;; iti prin^iprilly due 
to {eebleaeBH of tbf nitimHilar TCallx. allovinngofa^TtiDiubittouof flutiiM, oudto 
the fdmllowneiui of the polnM, whidi tJin^ivii nil the alKloniinnl riscera above 
tbr- level of (lie jielvic brim. If tbo uplrcii is* \fry liirj^e it may muKe n 
Mpcciot inccUiot; on thv U'fl ado of the bL-Uy, nomctinics rvnchiut; hclorr the 
ambilicuK. It nuiy 1* rrninrked here tbat ia aimca whore the livtr and 
imleeu cun !» fell below the level of the ribs vtb must not at once conclude 
that their aixe itt abnornml. Thfi organR may be mereh- pi)Bhe<l down by 
the ilepr<«Mou of th« ilinplini^nn i^ud tliiiiiiiinhed cupiioity of the thuras. 
Th«refii>re. after asoertaiuiug the |K)sitioii vt th*? lowtrr edge the upiwr 
limit of the or^nnEi ahonbl be efltininted bycai'eful perouiwion. In addilion 
to enlargeiueut of the Uver and splet- q the sut}erScial lymphatic glauda are 
aotDel-inies HwoUen, nnd cau be diBtlucOy felt latter than natural ia tlie 
BxiUfP and jrroiiift. 

Rt«kete is Dot a couae of pyrexia. If the temporatui-o rise above the 
Dominl lerel a (-oiiiplioalinn may lie at once HUHpectod. If ferer occur 
during the sta^ of iiiiprnvninent it nfl*>ii aniinuneea the return of denti- 
tion, and nbowR tbat a tooth lit pn^iu^n^ throu^b the gum. The degree of 
mwtiug Turtfs. If the disraiao l»c mild tho child, altbtiu^li [xUc, itt often 
excfptiounlly plump from orer-nouriabment of the »ubouLau4:uuH fat; but 
nzileea recoven- Ijik© place shortly tlie limbs (Quickly begiii to foul soft, and 
eooD the diild c(iu Ix- seen to bo evidently Miutiii)^. The complexion is 
nlwiij-s pale, tbv lower «vfUd ia fift|iieutJy distuIuureJ, and the boi-dera 
of tho mouth lu%-e a bluiKh tint. If great eulargemeut of ttpleeii be pres- 
ent the tint of tbe (aoo becoiii<^» peculiarly bloLHlIpBs and the uiueoDH 
braoea are very ixile, Hit-kcty rliildreu »ro ha*'kward in erory way, 
in mind nod bwly. Their iiittrllecrl KCi'iim lo grow ns slowly as their 
iRea. On nooount ijf tlieir inability to jotu in oiiliiiarj- cbildisU games 
th<7 are much in the sot^iety fif older persons, and therefore ac<|uiro an 
unchildish way of esprewiny themselves ; but they talk very late and are 
dull at picking up new words and plinutos. 

The pri>gi-o«8 of the diwase is «]ow, and iinle.'« the innanitary oou<li- 
tions whicb have led to it 1>e removed, it goes oti from bad to norse, 
Theee children often die fi-om some catarrhal ccimpltt*ati<m A bad diarriia-a 
is rmj dongerouii on hivouiit nf tlieir general weaknesn, and n cmuiMim- 
tively luild puhuonan' coturrb may prove fat^ through the softening of 
tbe ribs. I>cRth iTirely taken place from the intensity of tbe genend dts- 
iTTlirr Wheu iniprtivement be^^a under judiciouH breatnieiit, tJio genend 
tenderness is usually the first aymptom to subside. The cliild is ]e^ fret- 
ful when noticed and talua more interest in what passes around liia hvd. 




At tlio niime time the enfteuing of 1b« boD«<t dlnuniiibra, and na tht> nb» 
regaiu tbeir ttnuno^H the niiirke<l iinyn»vfiu(.'iit iii hn-nihinf^ whicJi n>«ulta 
from the greak-r rigiililj- of tiie clweUwall i-nniml cwinpe uotic*. Teothiiig 
rIho begins n^aiu ; thv WMling ceases ; the liellv is lus (UNtcmlt-i) ; the 
snouts dimiiiuli and all thesvinptomminderipi (jpeBtiuiintJvtnieiiU These 
ehi]ilr<-n oft«D become very atiiray ami slronij. tmt usuiuly retuaiu short in 
Htaturo even nheu tlieir full growth \\a» W-en nllniiH-tl. 

A fonn of the diuease hiia be«n di>Hcribeil which ban be«D cbIImI "aoidi 
ricketA." Ja this vozie^ tfaft nrtii'ul&r enda of the loug 1>otM« undergo 
rapid cnlar^cuicat iui*l liecouu t«jwlc-r on pniwure. Secouilat^ cylintlTiMl 
awellbga are also seen about the Uniba The tetnpemliirp is Linli. It 
aevms probable, from the investigatiooa of Dr& C1it«(llo and B«rl(>w, tliat 
tiieee cases arc iuotaiitrw of wiurry gtafied ou to ricket»». Thoy are referred 
to more fully iii Iho t-liapttT trftiiting «f tlie former ilitw-juw. 

Cbtn j/Hi'atwitM. — II LB not of leu llmt a t-sw? of riflLets remains iiucoiapli- 
cjitpii by BOme intercnrrent complaint, 'Die snbjeot of a pronounced fumt 
of riclkctfi luM but little reftiHtinii^ power, and is n-'aiUly iifli-i-teJ by any kind 
of injiuiouH inttufnre. But be is in addition pt-euliArl^- liable In certjun 
forms of deranf^i^mciit on iwwmnt of tlie sjwcial tendencies of tbts pliaw-* of 
lual nutrition. The scunitivcucHa to chills uimiifefltetl by a ricl:<ty child 
has l>t*u already rciuul^od upon. Tliis proncnt-HH Ut raiarrh rosy be lite 
conaecpteuce of the profiue and ready action of the Hweat-glandji. and it ui 
no doubt cncoiirftfjed by the child's practice, when his pcnqxmtions liegiu, 
of tlirowing oflf the covcringa of hia r<eiL The VBi'iou& luiiuM of ralArrb are 
iJifreforu csix'dally liable to ocrur, and pulinonatr and ijitt-stinal cntnrrkB 
are the most freipipiit of these dernngcmniLs. Few rickety lUitdi-en are 
witlioiit a <!ou>;li, and this irrmptoiu, on account of the untuttunil Hexibihty 
of ihi-ix cbest-walls, niunt, l>o alway.-« ruf^nnh-tl with anxiety. Tbe danger of 
cwn ii mild pulmonary- oritaiTb in llit-Be piitientK. and thv readineMt with 
which thJH derangement given rise lo coUapsi' of the lung, is rcfenwl to 
elsewhere (ece p. 467). To tliiw cause a lai-go proportion of doAtlis is 
due. Again,, moi-e nr l(r»« intestinal catArrh in a common denuigemetit in 
this difleHf^. niid nftt-r auy uiiuhuuI exposure the loosenesH of the boweU 
mjLV paas into a mvoro fittack of purging. Diarrbtea, on account of the 
great general xveaknos*, ia a Bource of extreme danger, and during tlie 
clinugeabhi t««aHons t»f tbo yom- many cliiklren are rorrtetl off by this com- 

Another peculiarity of tbe ricketj- state ia tiio curious impressibility 
of the ncn-oua system which manifests itscU by the ready oMuiTeuct- of 
various forms of spaHui. Itc/iex amviilniow are common, ami lanptgiamus 
»U-vhtiua is pi-nclit-nlly coufiued to the aubjcols of rickets. Catairh of the 
hiryux is also liable to lie accompanind by icposm, and therefore i:utarrhat 
ci-oup (larynpitia stritbiloaa), as ia elsewhere stated, ia a fretjuent «uiae of 
ansietv. nieao Bubjccts need not Iw further referred to in this place, as 
they ail rereive coiisideratiou in Hpecial chaptei-a 

One other not uneiimmon compUcatiou ia •.hromr hi/ilnxvphatun. On 
ocooimt of tlie Rraall size of the brain in many casM-s of ricket*. fluid is 
eflused into the i-ninial ca>4ty to fill up the reRiilting ^lace. The amount 
of serOHity is, however, seldom large imd rarely coinea (o bo a source of 

Au occaaiouni eomplioAlioii, altbooKh not a connuon one. is anite tuber- 
oufowVi. Tho disease iM jd-olmbly iu all cases tlie result of an sequirod tcD- 
deD<^ due to the prcsi^uiHi iu the baly of a wiftening cheesy deposit It 
certainly ia proiwrtionsts^y loss frequent in rickety subjuota ihaa iu children 

Idren I 



m. 143 

ffrer fmm thin fliiwnlor of nutriti'vn ; Imt it IB aftwwniy to bo awuo Uut 
rickvUi ilo«» uot pxl'IimIci tiilicrLiiloHiD. 

iMuguusU. — 111 a tuUd case of rickeU the prominent features are llie 
swelliut^of tli0 epipbyHen) fiids of the long boneB, the tiirdy eruption of 
I thu teell/. oud tlt« bockwunliifHii ui 1«iu-uliik to walk. If we notice t]i« 
-wrists to be hirge in » yaun^ c-hilJ. wc should u.t uiil-u ruuut tliv iiiiiiiber 
of luB Le«th and atili if he Ik nble to ttttuid aluut>. If fl child^ loii muuths 
old shows no sicn of a tooth, if hia wridts nre large, and if when held upon 
Ilia feet bin liiiilis iloii}>Ii- up ii(;lplrt»»ily Ij'^iiient}) liim, the^n^ can Ik little 
<loubt tliat h« 18 tbe 8ubj»ct uf rirkvt«. Even before the 8w«lliii|{ of the 
orticiihir «nA* of the bones haii coiii« on tho onset of th« diseaiw niJiy bv 
•ni»j>i-ctc(l. Big, fivf. fiabby iufauta are generally filinhlly rickety, and if 
a child sweatii profusely about the head, and is krpt covered at iiij^bt only 
witb great diiBculty, we am liavcr iittte doiibt ttiat the eliarnetf-riHtie k^h 
of riekcta are about to appear. lu &xk\i u oute attvutiuu should be iit oui'C 
Uircct«d to thu child's diet, tlio niO^l^uity with which La ts tokca uut uf 
doom, and th« state ua to ventilation of biii Kleepiug-room, mu that auy 
errOK io mnnsfcement may be promptly roirected. 

Id a marked vaste of ricketti the dufonuity of the <dieet, the bending 
of the bouea. the etilargeiuciit of tlie joints and bending of tbo riba Me 
aufBcieally charaeterisUe. Evmi the [josition of the patient as he eita nith 
his legs croBsed and his bead fallen btvck between Iuh sliouldorii, supportan^ 
ilia fe«ble spine by his hanila placed before him on the floor, enableia us ait 
<Hice to recognize the citse as one of welKdetined rirketa. 

The eom{ih>l4^ tiaeh-tbtnttas of the low^^r lint)>» in many of thoAe caaM it 
oftvu a efiiouH luixiely t-vcii to parents nlio n'^anl Ibu otli<>r aymptoiua 
with eompunitive iiidiilerenL'e. for they fear leHt tbe duld Hhuiild biai "^uig 
to be panUyBed" But idthuu^li tlie patient has no idea of even pliiciiig 
iits fe«t ui>ou the fj^rouud, and ciieti bitt«rly when imy attempt ib luadc to 
persuade iiiiu to do so, power of nio\-cment of the leg.s in iinimpniretT. 
If the ^in of the h'^'x he piuehed or (gently pricked bo at ouoe dravvu iiis 
limbe out of the way. Of other local *^mptom« :— The nature of the an- 
tei-o-poalerior s]>inal ciu-vature m rwwlily ahnwn by lifting the rhild up 
uutler the arms, when the weight of the jtelvia and lega at once caUHe» the 
imiaAl distortion to diiwp|»ar. A lnt«rAl curvnture i» distinguished from 
tlio cfTccta of pU-uriay by uutiug thu ptrescnce of tuKUB of rickt-'ts aud the 
absence of LlioHe of efFuHion into the criesl cavity. The rickety head (Hfleni 
trota a skull dilatetl by exiw^i of Huid by ita ahape. Inntead of being glolv 
alar it 13 elongated from before bat-kwards, with a oharocterietic (KiuarenesB 
of the funbcad. luid niorvuvcr thix Khapo of lieoul is ansuciutcil with other 
«-eU lunrkL'il nxma of rickela. Tlie fonlauelle doea nut alwaya funiuih 
tmstworthy evidence ; for although often depresHed in rickets and raised 
in by^Irowiphalii.H, tliette conilitionij luar be revcittvi). Certainty a. depreased 
foDtaneUe is compatible with a fairly copious etTuxton of intrfwranial 

Iq tbe present state of our knowledge no didcroutial dingnoi^is onn Iw 
made, dunng life at any rate, between rii^kcta and o^tco-mnlacia. C\u>ea 
when* Hoftening and deformity of bnne are present niuat be asaumed to be 
ricfcetK. Fortuoatcly, for all procticAj purpo^s. a distinction in any indi- 
vidual case is nnueoosaAry, ns tbe measures to he tiduptcd for the relief of 
die patieni are tha asine whatever be the correct pathology of Uiu osiieous 

Prognam. — Kokcts is not a Mai disesas in itself uuleasthe bony change 
be br wdroaced, aor even In aucb a case does death o(t«n ensue exceptaa a 



poimeniieiK-e nf ftome «ntnrrh&l mmplicHtiOD. An « rule, impniveiMBt be* 
gitm ilitvrlly itieitHurefl are 1ak«u to uuend Uic unvhotMome eondttiODt in 
wliirli Ur- luktieiit is lirinj;. Tlie dan^ni of pnliuoniin' cnlnrrh nnil &t4-lco 
tftsii* in a tOiiM with gr«flt deformtt^ o( chpst are eW-where referred to ; 
anil tbe wrious ooawqucnncit wliich may reRiilt d-nm <han-lKi-a in 'nn infiut 
reduced to a atato of ne-riu^iis woikncMK l>,v clii'ouic tual-uutxttiuii ucvtt iiut 
\t» insiifibvl upon. Of the oen-otis compUcHliuiw. liir^ugisniuti Htncln1ii!( is 
BOlDctinicfl a cAiifio of ttiidden dedUi, but reScx oounUBioiiB excatad bj BOtne 
trilliot; trrittuit raii'lv luivu tu\y ill i-vsults. 

Euliu-gi'iiient of tliL^ HplL-L-u. livLT. uiii) Ijmpltatic glands genenJK' is 
verv rare, but if present nJiouId excite greut auxietj". It ui dootp comuion 
to hiid «nliirf::eim-iit of tL« ^leen alone witboat anj offc-ction of otb«r iD- 
teniiil (jiviiuN III rirkt-ifl. as lias been aaid, tbe ispleen is oft^-o tJte seet of 
, Biinpk- hrtx'qrliutin. TIiih lusiuu, as it in an additional caiwe of anseDiia, 
DO (louI>t inti'(Hhice« into the cnae a (iiTtlior ol^mont of dniif^pr, but Uio 
dauber is dc-iien<l<^nt more upon the inteaatr of tlie rickctr process than 
ujxin the ilegrei^ nf splenic swelling. If the 8>iiii>ton)H of lickrts are coin- 
panitivcly mil't. nnd <Uic i*iirt> Xf uikcn to tOiifltl tlio rliild frrtni calarrlial 
compUi-ntiou^ the pi-cMmcu of a bi^ Bploeu dova uot iudicutv tbe probabil- 
itr of a fatal l^ruiiuntion to tho iUnL<Ha 

Age has no inHuence ugion tbe propnoeis of ridets, and vhtm tbe 
diaease occui-a as n HMjuel of inherited cn-pbiliH, it presents no apeoial diffi- 
culties in itx treivttneuL 

'Wilb i\-gHi\l to tb<; t}enuani>n<-« of the uiittif^fatly ilefomiities of bone, 
it is of1«n (wtoiiLuhiug tu note tb« iniproTPUicnt wbich tAkeH pLu<« aft«r 
recovery from rickets in th« defcrmities which Beemcd the moat uiilikelj 
t-o he reduced. Tjiu'ge joints grow maUer, crooked bones become almoat 
strni^'ht, nnd n diHtortod client will rseover itit4>lf in n HUipriKing manner. 
In ftntno children, Itowewr, impi-ovemmt f^-» on farther than itdOM in 
others, and therefore, while eiifourafnn^i the ptuontw tobelieTc that titer* 
will be coiisitlemble iti)))mTfnient. we uiiast not be too astigmne oa to the 
eorapletp diRapp^^oranco of ull distignrenient, 

TfViilfHfytt — In every coifv of rickottt our first cftre sboold be not to uive 
cod-liver oil or tonics, but to iu(|uiru iiitotbv conditions in which the uiilj 
is living ; to ask iibuut the foO(] lio is tidiing, tlu> (|iiaulity allowed for each 
m^al, the freqnencv with wliieh the meals are repeated, and the degree of 
cieanlineiw of the feedin;; npptimtua We aliould then tiiru to the mibjert 
of his clothing, the ventilation of his bedroom, and the oiiodwr of honra 
he i« pasaing out of dooi-s. Tbo real treatineut oousiitls iu nttention to all 
those imiM)riimt utittci-s. and not solely in the admiiiistnition of any pnr- 
ticulir ilnig, Jlcdinines are nn dnnbt useful as helps in th« treabnent, 
but their importance is trifling a» eompftivd with thiit of a refoiiunlion of 
the uDwhoU-some conilitions under which the failure in nutrition has taken 
phi^e. The reader is referred to the ditipter ou Ibv ireutmeut of infantile 
atrophy for geuernl directions with rv^iard to th« feeding and lUBnagement 
of young chilfU'fU, 

AlnioFit all cases of rickets have l>eeD preceded by sympt<Hns oi digctt- 
ti?e derangenieni or bowel complaint, ana unlew improvement has alrM<ty 
Ije^un we often lind signs of lotMencfs or intestiiml <l6mugeiDe&t still per- 
Msting. This should at once be remedied. The belly should be kept 
warm with an ample Saiuiel binder, and tlie chiki should lake a drop of 
luudaiium to control the undue ]M>riKtaltic iictiou of the Ixiwcte, willi n few 
grBimi of tho biotrlwuate of wodii to correct acidity, in an nromatic water 
aneeleued with a few drops of spirits of chlorofonu Uu-l-c tinioe a day. bi 


many cneee there in n Hppcinl <lifliimlt; tu (li;;eettng atnrch. la aliDaBb all 
iostADcee w« finfl tJint lliiii vnnetr nf (ontl hua. been giveu in greai axmM. 
The qtuuititv must be thnreforp ronwilcmbly r*>(luec<I, and Uiat tjiken 
fihonlitbe giumlvd vrith miJl, nx iii McUin's fut^. UvOT'i^exti-iictof mult, in 
doem of two or three tciiiipooiLfiilM Uin-o tiiiivn a day, in of ^reat Mcrviou in 
thc*») CAWH. If tlio cKilit l»> uu longer lui in&iul, the diet Khould be arriLnged 
OB directed iiudvr Ibc Lea-ling of "Chrooic Diarrheal " (see page C40). 

Plen^ of frMih air tihould be iusisted upoD. The child, immily clad, 
fthould be Rent out is all tniitiibte ««Rtli«r8. luid if care be tak«ii ttuit hia 
fc6t (ir« wcU vrormed before lie lewves tb« hrmiie, there will Im> little danj;«r 
of bin cntching cold. If the pntient have i-eonhed tlic age of eight or ten 
tnoDtlis be lihoiild bi* irarefiilly pafknd witli cunhinii-s in n peranibnbitor. 
and in cold weiitlu-r Hlionld iiUtiyn liftvo it hot boUlp to his fni?t wlii!<* out 
of door«. The reiitilatioii of bin BlMpiii{;-rooiu miifit be attcudbd to. A 
wnall fire iu the winter, nnd a Inmp placed in the fender dining the sum- 
mer montJut. will jiigure a mitfioieiit cin^i]ln,tJon of air tJirouf^h tJie l»«b 
chamber. Both tbo pntient and biii immMiate fmrmundinf^ taunt be kept 
scrupiilniiHly clean. Rverr morning tliu whole body should reeeiw alhur- 
mi^h wnjthiiip with soap find water, and be well sponged iu the evening 
before tlw ohihi i* put intohis oot On aecoiint of the copious penpira- 
tjous his l>ody Uurn, iin well um timt li&li>iif,-in^ to liid cott aoou beQOUieB 
aaturated with moisture. His uDdcrcluthiii;; uhuuld tlieroforu be cban^^ 
oa often as ia tieceBStix}'. Ever^' m<.>ruiug, too, hii> mnttreKE ikud bed-oov- 
eriu}^ must be thoroughly exposed to the air. The sheets aUo should 
bo cbunRwl (reqiwtitly iuid hv iniitjfiiHy aire«l. 

If IhenlKive meiiHiirfKuii:' pix){HTly attended to iinprovftnieut will ([uirkly 
begit). Directly the bowels hnve been got into a heiiltliy stiit* i'o<I-liver oil 
should be ;g;iveii. A quantity much less tiuui that uauidlr prescribed is, 
bovfcTer, Hufficient ; for ehililreii. infa-ntii pspecially, have ooinpanttively 
Rtudl power of digeotiug fats. It is hcst t« bftfpn \ritli ten dmptt of rho 
tigbl brown oil, and dtirii;).^ it«i ud in in int ration the hIoi^Im must be Mirefully 
watched for uiiy Hi>iK'i4ruQcc of uridigiated oil. The t|uaiitily can lie grnd- 
ually inrrenxed by a few drap« at a time ne long iu* none of the oil ia »(h>o 
to poas umligeHtml from ilie bowela Iron is abto uMfiiL Iron wioe 
(fll xx.-xl), titeexAJorat^d sulphate of iroufgr. ij.-iv ). or the tinctorcof the 
perchloride ( iR v.-xv.) — nil tlie>te lUf useful, antl are to be preferred to imy 
of the sjTupy |««p<i rill ions. The hitter are not fitted for rickety aubjet-ta, 
as the large t|u:mtity of sugar tbey contain eneouj-agua femii-utiition unj 
aridity, and often, indeed, by the dittturbiinro it nelB up iu Ibe Ixjwels, 
make*! oai-h dnso of the niediciuo docidudly prejudieial to the patient. If 
(juinine l» j^ven, the tminatc is the most suitable prex>araUon. One or two 
grvtiM nhoiild be HUH|>cnded in glycerine and given two or three times n 
day. If there is any tendency to acidity loft, after returtuigi'iiieut of the 
diet, the amraonio-eitmte n( iron ni«y ht\ given in a draught with a few 
grains of bie^rbouato of uodji and one drop of the tincture of nux Tomica 
buLwt-t-ii iiienln. 

Tlie salts of lime were at one time n>eommcndcd in tlie treatment of 
rickets, as it waa supposed tl)at the boue-:toft«ning waa dufi to a dvfioicxicy 
of Utne in tJie syateni. Iu pmctice, buwever. the use of these drugx has 
not been found of vaUie; indeed, tlie remedy, for any ^>ecial benefit it 
prolueei^. may ad w<^<l] not be given at all. 

The copious perspinttions from lh« head and neck arc alwayti a source 
of grKit nii^iety to the mother. They nui b^ controlled by apiuj'iog belUi- 
donon Uuimeii't to the pnrUi where aecrGtiun ia copious boforu tlw cbihl 
10 ~ 


is pat to bed. He may alao take one drop of liq, atropise erery night. 
Directly tte tendenieHS haa subsided steady frictions with the hand alone, 
or with oUre-oil, all over the body, eapecially along the spine, are of great 
service and do much to strengthen the muBdes. The nuree should be di- 
rected to rub the child steadily for a quarter of an hour immediately after 
his bath. In the morning the open hand or a flesh glove may be used ; in 
the evening it is advisable to employ warm olive-oO for the frictions. As 
the child improves and his strength begins to return, a cold or tepid saline 
douche, given as he sits in the warm water of his bath, will be of service. 

Care must be taken to prevent the child's getting on his feet before 
his bones are sufficiently solid to bear his weight. As his strength im- 
proves he seizes every opportunity of practising his newly acquired power 
of standing, and very marked deformiues of the tibia may be produ<^ by 
this means. In such cases support may be given to the limbs by the use 
of light, ptidded splints, and if the ligaments of the joints are much relaxed 
a fii^ly applied elastic bandage con be made use ol 

The treatment of any deformities which may remain after the complete 
cessation of the disease falls rather under the department of the surgeon. 
For the treatment of the various complications of rickets the reader is 
referred to the special chapters treating on these subjeota. 

QaiLCRKK «bo liv« in nuilAnous (3iatrict« un not exempt from fiffuc ; indeed, 
in early life the »yHlfm ia liaid to Lie jparticiUiu-ly MuaccptiMc to tin: nt-lion 
of tJie maUiriouM jiowctn. During inmnay and up tci ti* nge of fire or nix 
yoara, the fever may assume peculiar nhorarteni, ami unlesn (Utfiuteil eai'ly, 
and promptly treiite<l, may «veu ]>rove fatal. In tui^ra iiilvanc«(i cLUdliuod 
Uie lymptoms pn-dcut little vtu-irty from those met> witii in iidult life. 

GtUBOiion. — A^uH is uu {•mleiiiic diseaBe, wliivli lk tjx(.'il«<l l>v I'^^wideiiue 
in a malarious neighbourhood. Aa ague-breeding district is usually low- 
lying, marshy or ill-dnuiiRil, «i»I liim a more or leH« imious soil, compoaed 
laiyeiy of rottiDg vegetable umtter. Still, these couilitionn are not a-lirays 
found united in plAC(>8 wh«r« iigiio AbotiuiUi. A diitiut«<;rat«d rocky fioil, wliich 
ia vary porous, and io saburatod with n-ntcr to vribhiu a few incbeit of tlio imr- 
(aoe, rosy largely geneintx) the malaj-ioUH poiHoti. although deraytng vege- 
table matter i» eutirely abst-iit. A noil tbuet deleteiioUB it* i-etidered doubly 
□ozious by digging below the 8\irfikC6, Indeed, in some coses n spot previ- 
ously huilthy lifiM becu known to becuuic uuUiuiuuii afttT distiirbouue of 
the soil for building or otli«r pur[ios«H. Kven a miUarioitti district i» only 
poisoDOUB at pertain BeasooR. in tcmporate diniateti the siiriug and au- 
tuniD are the l^;ueit4tl periods of the yciir. In the tropica uie miasuis is 
evolred in the dry bot Maituu which uuct-eedft to the periodic rains. The 
maliu-ift is thrown out from thi- soil, eupv^^'ially at uigbutiiuc, find risers to n 
certain distance from the ground. It la always more int«U!>e n«ar the BUr- 
faoe, beilig apparently more diluted or )-Anbe<l an the <liata.nce from the 
earth increasM. It may be imrried by the wind to a cnnsidera>>lo dintance 
front the spot where it hivt been g«'noratod, but afffwars to be incnpable of 
paanog a brood sheet of water, and even a bond of trees ia found Lo arreitt 
thA int>gn!Ba of the miaaina. 

AmongHt the resi<leiitR of a malarions neighbourhood tlie disease is 
very comoion. The children living in the district are said mroly to escape ; 
for CTeu if consideretl healthy thpy will be found, according to SLeiuer, to 
ban tlie spleen vulnrged. Even the new-bom infanta of rauthers who suf- 
fer from intermittent Cewr may be found at birth to pruBeiit the enlarged 
spleen, the bronzed skin, and uU the other aign-i of » pronounced malari- 
ous cachexia. It lias even been oArmed that tliu milk of a nu-bectic wo- 
man is (■apid>Ie of eommunicfttiog the diiwuie ; but tbiti »tateuie<ut roijnireii 
farther pnxif. 

itorhid Anatomi/. — Wlien cliildren who hare bef-n subject to ague die, 
the only constant leidon diseovi>red in an enlargement of the spleen. I>ur- 
utff an SiOUte attack, and for some time aftorwardii, tlie ol^,/nn is engorged 
irith blood M OB to be suvcrul limes its natural Bute. It a(t<.-rwardri diniio- 
ishea in bulk : but if tlie child remain iu tbe malarious district it coutin- 
to be harder and larger tlmu Duturul The cut surface is then pale 



nml •Irj-ioli, witli wbite Btri;v from llmVcned trabeciiljE% and eowelimea it 
liriM !i tJtiiy tiut nr <-voii a sprrklei) iL])|>i-Hnuico from durk ffray spots. Ilie 
cHjisiiIc i)i tliickoiM^I mill r>rU'ii r(!Ii<^ rcul. llcsidc^ liie M|<tpeii, the liver m 
tdho cout^tod duhDff ao nciitc altacli, ncd iifterwuivlfl rosy remain mor« or 
lesB enlaTRed. ' 

Si/mjilomf. — In early life ag^e mav occur eitlwr in the intennittent or 
rpmitt«iit farm. Ilotli ni-o (•ainmoa ; fur ultliougli iu the odiiU tlie rftnit- 
h'tit form ix rarely M-fii, except in the tuore eorioua vuricty of the i1iiie«8e, 
wUicb occiu's in tnipii^ol I'limatt-K, in tlie youn;; cliilit a cuuipiLniUTcly fee- 
ble doso of tbe poiHon may pnxlucu u prufuiuul (■IVect u[kiii the oonstitu- 
tit>u, mid excite fever of the remittent type even iu n iemferate Koue. In 
most cAMft lilt; foTer in cjuotidiAB, but it iimy l>e tertian ana eveu, although 
i-aiolv, quartau. Th« thrva StMgw of tho nttark are umially to be r»oog> 
niaed ; httt they iire ksH p(>rfe(*tly miu-kcd llittn in tlio ailult, nnd Aro often 
diHrHtli'riftei) l>y iKiniliiir t€atuT«8 nol. found in nftcr-Ufe. 

Alt oflt'n liappi-iiH in the cnse of the a«lult, the nttwk tuny not come on 
for some coiiwitlcnibU' tiino after pxjjoeure to the mnlnnouR intlueni'e. In- 
deed, cases At'e 60mctinae« met with iu wbich a ehild, who in tree from fev«r 
while h« lives in the a^ieish district, oulr bt^ns to tnifler after bo is re- 
moveil to a iiioip henitliy ntUHtion. 

Tlio eold Htai^fi may hff^n witti verr violent i^rmptoms or may giro 
only triflint; iiuliattiuus of il« prriwouc. llie child may hare a fle>-en] rigour 
like an udult, ur may be taken Huildeiily with a ounvuUiire Mucure. If the 
latter the lit ih riiruly re{}e:ited, bnl in fuUuweil almoot immediately by 
hc«t oftikiu and all tlio tiymptoiunof the i^eixiud slai^e. In infanta neither 
rigoiii« nor (^oiivnlwoiis mny be seen. InsteAd. tlie baby eeems drov^ ; 
fre<[uently yiuviii^ ; miinotinieft 8tr«teho8 it«etf; is pmmli and fiytfiil, re- 
fofiing the )>ottte ; and looks pale and proatrate, vitli perhupn some Itridity 
of the lipti nnd linger-nnila. In raro roAeii tlte handtt nml feet are I'old to 
the tourh. Thi)* ntage in UKUally nliorL The teniftei-Hliire riN#a jwo^rea- 
Riv<Oy thiYiti^liniil, anil even at the be^niiin(f, when the child foeUrold or 
actuidly shivcn-i. is above the normal IcvuL Tnwiuxis tho end of the stage 
the mercurj' may regiiit«r between 103 and 104 decrees of heat 

The hot etii^e is usually better marked. In thiK the akin ia distinetly 
febrile ; tlie child ie drowaj- and looks ill ; if not tliiaUed, tiie fao* is pinched 
and pale ; and the bend i» aaid to l>e tender. Tha tongue ia covered nilh 
a yeUowish fur. nud ncoonlint; to Dr. Fniiliii(j:ht it is not uniN^mmon for the 
throat to be eon^gted with a uliitixh depi^it ou the toiiHila. The ehihl 
i» usually thirsly and drinks i,'reedily ; he often coughs— indeed, aoou^jb is 
nud by Dr. FruitniRht to be a constnnt sjmptom of tlie ait»<'k : the ptiW 
is rapid, feeble, nnd comprewdble. Prfwiure on the liver niid uplecn elteila 
eiffDB of ibftcomfnrt, and both thcHe orfrnna oii pnlpati^n are found to be 
eninrged. The eliilil oftcu >-f>mitit. sometimeB brinpiip up bile ; and the 
boweU may be reln^ed. OccaKionally an icteric tinge in notioed on the 
skin. There is one tiymptoui aoinetimeti met with in a mnrfced ease which 
must not be oiiuttc<l. Tliia i* a Rcneral bright retlncww of llio Kurfiicc. Such 
a mah. aoi^omiianicd by a liipL lenij»eratin'e, ami following rapltUj- upon u 
riffoiur or ait attack of cnnriilsiDUH, nonlil Rtron^dy sufrgeat scnrlatiiui, eq>fr- 
cially if at the name time some redneaa of the 'tlu-oat «ould be detected. 
Throiiph thi» «rta«e the t«mperatiiro codtiuuoa to tiae proKresiiivdy. and 
townnis the end lina reacJied its uinsimnni. wliich may he HW' or hiL'her. 

The third orKwenting rtage ia very imperfeetly dorelopcnl in the mfaut. 
Older children may buTst out into .1 proftue pcTwpiration like tlie aduH- 
Still, whciber tbo lUaeuae end in awmting or nut, there ia a raniarknhla 

fall tit temperature at the eii<l of the hot mto^, aiul the tlicrmoiDetor will 
often mark 100' or IIH^ whore ATtr^ wliort Uiao Iwforp the pjrroxis b«l 
been as lii-jh jm 106' or 107'. At the wuiw tiuit- Uiiit this diminution in 
the bodily heat is nolieed Iboro is uxmillv it pniftiue tu-cretinn from the 
kiilne},-», aud the chihl p— OM a large quautit)- of hiij[>iU urine. Accordiu;:; 
to Dr. Uee's obwervationK, the proportion of urea iitui chluritle of Hodiuui 
w grentlv iucrvMecl iliirin^^ the hot amjfo, nliilv t)it> phusphateu arv 
(UmiuiMhei As the tTiipf^ratiirr falln the niuoimt vt urea and of chtoriUo 
of sodiuiii ilimiuiflb, whilu tLu pi-uporliou of phoHphat.e» tHatigniented. 

Tbe dunitioQ ai the »ttiick varies. The hot otago, whicth loels the 
longest, niny occupy kix ur oi^ht linuTx. Aftor tho uttnek is over, the child, 
if he is BuHoriDi; from the iutenuittent form of the diHcaae, flpeinn quite 
well until tlio next attodc be^a. If thu fever is of the remittent t^-^w, the 
patinnt romiuiiR more or lean feverish in tbe interraL Hp. in thirsty, bu 
bttlo appetite, is hwguid, peevish, and restless ; loobi pinchcil awl ill, and 
turaally Lowa flv^b. Tho vk-astiug is sometiiues iucTuiaed by a troublesome 
diairbcea. Often tho fever, at ftrst iutemilttent, may paHa into the remit- 
tent form : and Uieu, again, iu its pi-ogrem towardB rccoven- rctiim to the 
intenuittent t\'pe-. In many canea of tlie rt^mitk'iit furni uf the disfiuse tho 
fever runs n IftxH nciite coume, and llie teitipenitunj, althuiii^h pBraisl^utly 
elevated, doea nol reach the high level corumon in the sliorter and nbarper 
attacka Thus during the i>an>xyama it may rise no higher tlian W2^ or 
103'. and during the remissions nmy be little over 100°. 

In children of feeble conHtitntinn, or reduood by dironic disease, the 
fever may asfluraft very malignant chaj^cterm. "When the attack comee on 
tbe patient bocomua stupid and druwHV. and then quickly passes into a 
state of coma from whicli he never revives. Such caaes are never seen in 
England. I>r. Lewia Smith states that he has twice wet witli tJiia form 
of the disease, and llittt iii eavU in»tAUce the attudc pmvetl fnltd. 

Children who live in itialarioiia dintricta often exhibit sij^iis of ill-heulth 
without sufforiiig from ac'tiial attacks of fever. 8uch patients are thin and 
weekly ; the akin is of a i>eculiar pale bistre tint ; the mucous membranes 
are pallid ; the apptitite ia poor, and the Imwels are costive or relaxed. 
The spleen is perntniienUy eidar^'ed and Lard. If the anffimift is extreme, 
eedetna of the Ic^tk and anlih'H may be noticed. Sometimes, however, 
Gederaa in these canes is due to disease of the kidneys ; for ha'nmtiiria and 
olbimiinniia are said to be not unenmninn symptoms in chil^lren livin^jf in 
ajnie-brwirding nflif;iibourhonda. Indonl, in eonntrion whore malarious 
fcr\'cr is prcTulcnt the origin of Bright'^ diM-aev iu tliu child is frcqiicutly 
attributed to n previous attack of ague. Cntnrrhu] pneumonia is said 
wMnetimea to compUcate the illness and may even pass into contirmed 

Tbe more obecure forma of raalftrious fever, which are not uncommon 
tn the adiilt. in tlie child are very raro. Brow ague is unknown. Bohn. 
however, states that he bos met with an intermittent torticoUis which be 
believed to he refembU* to a miosomtic atuae, and Dr. Gibney baa de- 
scribed an intermittent xpinnl paralysis alim at malai'iotts origin. 

DiOfiniariA. — Wlieu t\w di)M!iuto aKxuiiies the ordinary fonii met with in 
tbe adiilt it is easily r^cogui>;iHl ; but wlion, >i« often happens, especially in 
iafantA and the younger rluldren, thn stages ni-e imperfectly marked and 
tbe symptoms indelinite. tlieie is nnmh ditHfidty in the diagnosis. If the 
ease ooenrtn an aguc-br^H^'iling district, sudden illni^sa and prostration with 
a high temperature Hhould ainiiys exciU^ Mur HtiHpicious, especially if uu 
evident cause, such as vomiting or diarrbieo, exists to expliun the i ' 


syinptomd. Aftern-anls tlit; midiltrii (iill iii tlie teini'prntiirc Trbich oecura 
at t)ie end of Llu> liut Rtaj^, and Llie rapid ivtuni uf iip]ju.rL-ut UcaIUi as the 
attAck pnaaas off tlie»« syicptotna, comltined with «tilarc«m«ut of the 
8pk-c-D. iin; -r^ry eung^Uve ot iiialurious nii^iu. Wli<!n on tl>e next day. or 
tliH dnj after, the munv plu>u(inieiia recur, ending an befom iii nmxireiit 
reoawry, tbe nnture of tlie illiiew) «iii iio lon{;or bo niisippmhonded. 

Fit8 of ngtic HonK^timc-H occur in fbildrrn nJio arc :ioL iit tlie time Imn^ 
in a molnrioiut diatrii't. If ne were atMldpiily called to a child of whom 
wo hikl no ptwvioiDi knuwlod^c, and found liim liwldng ill witlt n vory lil<'L 
temperature atHi ^((as of severe (^tiMtl ymkatum, w« sboiild bo justided 
in repiriling hia rondition witb fprsje amirelipnMioQ : for lliu fact of his 
haTinjr iwen Intcly r\pnfiod to tlin Sj^ue powon would pmbnbly not be re- 
ferred to. In 0iii'h A oa»(', niter n rsrefnl exuuinntioii of the pAtiftUt, w« 
ttbould bu able to come to no roucJuniuD, and tiii^LI pn>bAblr Kiutpcrt tbo 
omiet of one of the esantbtimata. It would be only on Ibt next yiitil. on 
finding tbe pntirn!. whom we bud left in ho appan^utly fterious a state look- 
tug aii<l ffHAin-,' wt'U, witb n tiontiat temperature, tliat tbe lukture of tbe 
ilhiFKi would i«ug<;f-Ht ilMclf to our luiiidH. 

If. duruig tbe hot kIji^b, i\w body btwomcs cni-»red with a bright red 
rash, this symptom, combined with the hit^b tempoi-atiire and porbapa Blipht 
rednetm of the tliront, may raise stronp BUfj^iiciniis of scurlntiiin. If, how- 
ever, we arn awnre tbiit the plienonitiunii may ot^riir. and find that liie rnflb 
Rid»id(-ji iind tlifi t4'mpiCTi»tnro tnlltt compb;tely in tbo course of a few bourn, 
we abould ruitcrvc n positive; opinion lus to tbo rt-id uaturi; of tbv vruptiou. 
^Vbvu. Iiitur, tbe Hamt> ]>bcnomi-nib arc exactly reproduced, tbo nature of 
tile L-ofic can be no )on<;er doubtful. Dr. Cbeadle ba«i iiL>port4?d two sitcb 
cneoA. In one — a obild aged two yearn and nine moutlia^-tbe illBeaa 
befj;)Lii ut a.h. with a sliarp riiroiir. A hot Imth which was immediately 
given brought out a bright i-eil niKb oil over tlie body. At tbe same time 
thp skin was diy and biiniint;, thi» t^mj^emturG 102 , and the pulse 110. 
There was no soreneita of the throat. At the end of three hours tbe rash 
faded, and tbe ne\t day the rhild wiih playing about as uHuaL On the fol- 
lowing day — tbe tbird— an exactly Hiitiilai' attack took place ; and hUer Iba 
phenomena were again repented a thini time-, (juiniue waa then given, 
and tbe itfjuo ilt« quickly come to an end. In a caac such aa the above, if 
there ix do redneKx of tbd throat tbe resemblance to Hcarlatioa is Ichs 
close. Even if tbe throat is sore, tbe peculiar puiictiform redness of Uie 
fioft palate wliich is so comiuou iu Hc^ulalina bt waiitiug; and, moreOTefi 
tbe redness in the fauces in leas generally ili^'iihed. 

Wbr>u ague nsfiimieit tbt< rniiiittent type, aa it 18 apt to do in feeble, 
badly nourished children, tbe diagnooifl ia leaa obvious. In malarious di»- 
trictti it i» will to (tti^iioc't ngiiu in all oases where pyrexia appears in a 
young child witboul I'vidcut cauw-. SlilL Ihe source* of error are niinioi^ 
ons : for a probable cniiw of tdi-vaLion of temperature, mich as dentition, 
inay be present in a child who is Ruffi^riug from a real ogu^di attack. 
Perlmpn the best rule in doubtful rn»e« in to pres^^ribi' quinine. We can 
do little liarm by Ibis pmctiee, imd may do great good by putting a atop at 
oin«0 to aUocka which in weakly eub;eet«, if not arreated early, laav pro- 
duce Tcry aeriouB conaetfuencea. 

Prtujiwns. — If the duiease be recognised tind treated promptly it can 
uHually bo controlled with eaae. Tlie fatid cases are tboao in wfiich the 
real nature of tbe illn«w ban been miMa[)pr«bended and Bpecific treatxnenl 
conaeqiieutly withheld. AIho, tbo exceptioual cases wbere ibe child ap- 
pean to be oTerwhelnicd by tbti violmtoe of the nudaiious poison, and 

paiweft nt^Mdly into a stAt« of coma, nrv said rarely to «Dd in reeoTerj. 
But ewii iu thcM.' coacM, if tlic cause d( thtt s^mittotiui wero recopniBwl 
in timv, it iti poMtible that ^nergetir xtimiilation and the use of qaininp in 
lai^ge doses hy enema or bypodf^rmit^ iiij^'oTinn mij^ht bo Ruecemfdl in 
STerting a fatal issue. It miutt not l>c rui-f^tt«!D tiuit iu umliuions dia- 
trictfl the specific fevers, and indeed aimte UlQesHes generallj, tend to ran 
ft moxe severe counw than iu healthier n<>it;hhour)inoaB, and that ma r rule 
^ndemics have a high rate of mortality. Childn-ii who siifTrr fmm tliu 
ague cachexia aro Imd xulijecbi for tlic vmptivo fevent ; uiid in lUl hucIi 
ottBes we should speak with coasiderahle caution as to the patieut's (iliances 
of reooveiy- 

Ttvatmcnl. — Dii-ecilj thp esistctice of ague is recognised in a child iqw- 
eiflc truatniont iihotiM be Lad nicoureo to without uuuoc^essary dvlay. Chil- 
dren bcnr fjHinin© w©U. A child of twelre montha old will take'a grain 
and a half of the »uipliat« of quinine three times a day, ood the fever will 
(luickly yield to tliin twatmenL The best way of administering the remedy 
ia to rub il up with plyforino and j^vfi it eitlM^r in n spoon or id a wina- 
dLUBfdl of milk ; for milk holpa to conceal the bittcrccHu of the drug. 
The medicine should ho Roiilinuwl for a few wvc-ks nftcr the atfaicks hare 
eeoaed, but he given in diminia]iE<d (juantity or less freipient doseii. At 
the Mme time it ia dfsimble to remove the ehild fram the malanoiis iioi([b- 
boorbood. If tliLt ha iiiipumiblu. it in well to ^^i\-o a dosu of quiiiint tvrica 
a week for a considf nible time uft<>r the subsidence of the seizureB. 

In cases where the diild vomits the quinine, or where from other roa^ 
KHia it is not deedred to admiaister the remedy by the mouth, it may be 
thrown up tho bowel stinpetid "><) in n small quantity of mudlage. or may- 
be [^iveu by hypoderiiitc iujeeticiii. In th<! former cjuk' the doB» must be 
double that previously reeommended for administration by the mouth. 
If ttie remedy is administered mihcutaneoUHly. Th*. Rnnlving recommends 
that the neiitml sulpliati^ of rjuinine 1>e u«k1 freshly dissolved in warm 
water ; that the syrinfiC! and Rohition bo lK)tli warmf'd before use ; and that 
the injection bo nude very slowly, diutributin)^ the fluid at the aimo time 
amoDgcit the iiiterstiirea of the cellular tissue by the toi-efinger of the left 
hand, so that no lump \r left to mark the site of the puncture. It is found 
that wanninK the aoliit.ioii and the syriu^ not only losaciis the pain of the 
operation, btit also nxlui^eM iIk^ U;uduticy uf the (luiuiiie to duposit itaolf 
quickly in tbe cellular tiimue. If iisod cold the quinino is almost always 
deposited at ont-e in a eoUd mass before absorption of t)ie sohition ens 
take place. This is, however, not itijurioiie, but it reti-mls ttje beneficial 
effect of the openttiou. The quantity of the drug tlius adiuiuisl^red 
abould he a fifth of thai <;riveD by the mouth. For on ndiilt the dose is half 
a graia. Probably onc-sixtli of a gram would be a suitable quantity for a 
child of two or thre^ years old. In order In prevent corrosion of the 
ayrinco it i» ndriRiblo direutly nft«r the oijeratioii to wash the instniment 
ia hot vraXvr and dry it carefully, and aftorwoHs to oil tlio «crow welL 
Iftateail of the aidpliate the kinate of ({ulninc may be used. Mr. I). ColUer 
haa recommended this nilt as the more suitable on account of ita sohibilitj 
for hypmlermic administration. 

In some ui.'«e», enpvciiiUy iu the older children, where there ia much 
aeote enlargement of the li^-er and spleen. ({uiuLue seems to be useless. In 
tbSM oases it is of great iniportauct? to retluee the congestion of the liver 
btCon beginninji tlie quinine treatment. Tbe child should take at night a 
dose of gray powder (^t. iv, ) with jnlapine or compound scammony jHiwdor, 
and the iction of the bowels should be kept up for a week or two hj ' 


of BOme aperient aalina Sulphate of magnesia ia voir useful for this pur- 
pme, given with dilute sulpburic add and miU a grain of quinine for the doe& 
The medicine can be made palatable with spirits of chloroform, glycerine, 
and tincture of orange peeL After the liver has been unloaded, the quinine 
treatment in fuU doses can be returned to, or the child can take arsenic 
( ITI T.-z. of the solution three times a day for a child ten yeora of age), «ith 
or v/ithout quinine, directly after meala. 

In the more cluonic cases, a combination of quinine and arsenic with 
iron ia very useful It ia also of great importance that the child be re- 
moved from the malarious district to a bracing seaside air. Moreores', he 
should be dressed from head to foot in flannel or some woollen material. 



RiiETMATic infiummalioD of the fihroun tismieH ib a common afllirtimi in 
early life. In chUilbood, indeed, ibere appears to be a ponilifti' teiuienc^ 
to rbeiimiiti-im ; ruid in ^ang pmnlc tJio diacatu) may ruunune v<>ri,' fipc4uiU 
cli&RK-t(;ns Till' joints ttn gentrnxly afftxluti but otiicr libruiut BtrurtUTL-it 
Huffcr Hs tn-U. ?bl'>ri- ofU'n tban iu tbt; anlult the arlioulAr uiflAmiimUun in 
ab«K>Dt. ajid not infr«queuUy it is verj' partial miU taJces an insiguitiinut 
share in tlie ilbtess. 

Tlie great iinportanoe of rlietirnAtisiii in ohililreu is due to tbe infUm- 
mstioD ID aDd around the lii<art, of wliicL it is su fretiueuUy th« cause. 
The Uatfffi mnjonty of coseB of hcnrt diH^nee are the con&e(iaenc« of rheu- 
matic endomnlitis occurring in exi-\y hie. But betudes ttie heart other 
fibnMM sbiictureH may be ttttacked. Thi^ pleura may be affected ; the 
meninges of the brain And t^pinal cj~ird inny sutler ; and tionictimeB fibrous 
ti8sni(-« in otbior nta&tion« nmy hv implicated, &a will be aftcrwmrds do- 

Acute rheumatiian in said to bo mieommon under five yeant of njje ; 
but the accuracy of this nssfrtioii i« oprn to (-pu-Btioii- Infanta an«l yoaug 
cliildreu iiuiy uot nufTcr from much artiL-iilar Kwi^Iliu^ and Jioin. but it is a 
coniiuou exporipiire to dt^t«t>t ii cardiiu; murmur at the mitral oriScr iu a 
youug chiJd. nud to dixcjver, on in(]uirt-, tbiit the patient had HOiue week.B 
or montbti preTiously beeu ftvcriali, with a httle Hti&eee and tenderness 
of ODB or more jotittx, 8)'iiLptotUM a»i]>ly suBBciont to eHtn)>li»h the rheumatic 
origin of the cainliiu.- diHciMt^. 

Caiitation. —The principal cause of rhcmnatiam ta exposure to cold, or to 
cold atid (bunp. In youn^ children and infanta a ver>' ali};ht impreatnou of 
cold may aamce to set iij) Uie disrane. Thus, I hare knuvrti a young child 
aspOHed to draught from Ihct mirscTy <Ioor, wliile Iveing dried, alter a bath, 
befom tltv tin:, xuffcr shortly nfti^^rwnrdH fi-oni ettiffucAS and pain in tJie 
luuwsi and endocarditis. Sudden changes of ti^mpurature arn fiivourable to 
the production of rbeunuitiHm. In IZnglimd the iIiHeose ia much mure rife 
during the spriu^ and the ftutumn, when the eveninga suddenly turn chiUjjf 
and (lamp, Iobo in the winter months vben the tetapemture in more um- 

Many inllueueea favour tlie action of cold and tnoisturo in producing 
Kfaeunwtism. Family tendency will do thin. A Ihrtre proportion of rhcu- 
Dtatio children cnme of rheumatio parents. Again, iircTiuua illness of the 
aaote kind predispoBSa to frRsh attacliR. When n chilil lins once sulTerod 
from rtienoMttism, h» ig very likely to suffer from it a aecond time. The 
atat« of llie health nt the time of the cxpo»ure oxertB some iuilu'-ncr- The 
exiatence of oatarrb of any muania membrane reuderti tlie ijatiunt wry 
■enstble to cbiUa, and makcR exjKiaarD very daiigerouB to a child of rheu- 



ni&tif? t(md«nmeR. I«atlT. ncarlatina pratlispowe with peculiar foroe to 
rlii-iiiiiiittHiu or to A disease iiKliflUn^iHliftble from it 

Af'rrind AtvUumy. — Wben a joint beoonaes the Mat of rheumatic in- 
fiuDiiuatiou, there is roddttDicff of the i^nom] mmnbnno lining th» joiot, 
the «^ovi&l fluid is incTMUMM in qaoLtit^ sad often milkv, imd there is 
some effaiiion of Amd into the muTtKmding tiawica. Bujijiui^tion in the 
joiDt is very mre. 

In poricorditw tbo poricardinm is r«f1dened and snfftincd, ozudatioo 
of l^'Dipb oocura on the seruuit tntrfaco, luid fluid lh into the cavity. 
The aeroiiH fluid and the more hoU«1 Irmph vorr ^Teatly iu amount, axid 
either may he in exceRx. The quantity of fluiiL throuu out ia mnietimea 
cnormouN. It may bo cluiu- or oj>h14-sc«iiI, or tint«Hl r«il from blood. 
HoinelimrH, an iii plcumy. oltLuu^'h fur Ifw frciiiivnlly tbim iu tJiut disetiMr, 
IJm) fluid is piinileitt The laj-er of Iruijili, also, nuiy reach ii prwit Ihidt- 
ness. It may l»e smooth, or pitttd with hnUn Uke fthou«vconii>, «r ribl>«d 
lik« tite afH'*ta»ii. Soniettiucs the vi«ccntl and ijarietal layera are unifvd 
by Roft thick Imnds of I\iuph. U thi> indnnuiixlory proceM in thw [M^rioir- 
diiiiii iu ftbvere, tho hoort BubstAnce towurds the surface is gjeDeraUy sof- 
tcnoti to a rerlain extent and wfiakeaed. If much Ivmph has been ihron-n 
out, more nrlrfw ootijpl^te adheaou is likely to taJte place, after ahaorp* 
tioQ of the fluid, bt'tweeu tlie opiMwad surfaces of tho fteroua membrnnr. 

In e&dooorditis the mca-bid a])p«ftninc««, when not congenital, are 
limited almoat invariably to the left side of the heart The vnlTes become 
thickened and aofteued. anid very Bonii gi-anular on the mu&ca The 
granuktiouR eular|:(R and develop into the MM»lled vegetatiouB — oat> 
ticrowthn froui the fibrous tiKsue of tiie valve which may vary p^^J in 
■hape auil size They consiKt. of connecti^'e tiinue mure or less iwrfectlr 
or^riLuiMKl. They are UHually limited to tlio auricular mu-fiioe of the valve, 
and uro often jmitially oovert-d by librinouM deposits. Orauulatioos may 
also develop on tJje chorda- leu'duioic. The iHtfteued titwue o( the nilvc 
may tear, or tho ehordw teiutineio may rupture ; and tho tfiuuou of the 
valve and tho doBure of the orifice may be etrioufily interfered with. After 
a time the valves may become thiokeued. oontnwled, and hardened. 
BometimeH they adhere to one auother or to the wull of the ventricle- In 
this way. nlnn, ti\o proper closure of the openitiET may be impoaaible, nnd 
the ojx-tiiii^ itself mny be uniTowed and altered in ehape. 

Ulccnttioii mikv takeplaee, ae.rioualy aJfeeling tlie %'alre i1w;U, and tcnd- 
iuc to produce other ^mve eoiim-fjuonoca. It \» the tmahing into the eir- 
cuuitiuQ ot fibrinous deponitii and particles of diKinte);mt«d tasBue from the 
ulcemtcd surfiiLH; that proilucea eniboliam in distiint orf;au»— the bmiu, tlia 
kidney, or tJie Hpleeu. 

St/mptumf. — The disease begins suddenly. The child, if old enough, 
complaiiiK of tx)ld. and 8it« over the fire. Hu id uuwilliut^ to more ahoiitt 
sometimes vomita, and may feel some stiflnetw of the nrtieulatiouH. Soon, 
pain tH eomphuiied of iu one or mure joiutft, ajid the cliild takes to his bed. 
When the patient comes under observation bis temperature is moderately 
high — 102 or 103''. His skin in jTeuerally moint mtb a sour-sinelUiij; jter- 
qiirntion, and on inspAtiou we find the afteeted joint« touder, swollen, 
and BuflFueed with a pink blush. The ohild is thirs^, has Uttle appetite, 
and hia tongue in furred. The uniie is high<ooloiired and snooty, and lA 
often think with hthates. The bowels are confined. The patient may 
wander at night : ho sleeps badly on account of the pain ; and for these 
luoaona (pain and want of sleep) his face is often hsggard-looking, and his 
expressinn disb-ened. 




The pwn M nt finrt of only moderate Bererity, bat fifrndnallj RrowB 
worse. Aa Ions m the ctild in (juiet tuid uiKlisturbcil he rony oot moke 
murh coraiiUint ; hut if tin? liunh is touchwl, or .the herl is Rliaki-n, he at 
onco shows mgiiBoF tlistreHx. The degree of pnin and the ninount of m,-eLl> 
iog nrouiiil thv joint ee«m to beitr no rcl:itiuu to oiic ituotliir. Thb Krtic- 
iilAtiouM aOectect arc usuhIIv tlii> Imtr^i' oiie»— the hipx, tlie lctit«it. elbowa, 
ankles and vristA It is @xo<']ii>oiiil] for the aiuiill joiutH of the lingera 
nod toes to be painEul oud ewollon. Uett&Uy one or two jointn are tirsl 
attacked: these recowr, and others become inflanted. The wiiole illiit-ss 
may la«t a rariublc timp. but the duration of the inflnniiiiiitioti in eadi 
partitulnr joint i« ooinpJirAtivpIy abort- It uuiy pass away in a few hoiirs, 
and ninOv iiiHta lon^^er than a diiy or 1m^ Sometmiea. nflei' leavin;,' a joint 
and jMNsing: to another, the indutiinintion retiinia to the joint lirHl aJTected ; 
and it) thia way, if the illnRi« hn a Jun^ one. tlie Kamn joint may iw at- 
tacked Hiiaiu uod n^Eiiu bc-forv the energy- of the dineiuso is cshatutod. 
Even when the attack appL-ars iv hf nt iin end. a midden retiim of the symp- 
toms may diatress and disappoint the patient and his friends. ReliipseHare, 
^•fy common in rheumatif fever, and Hie STinptoms may return, after a. 
TDon ur Ipm complete suhsidenoe. two, three, foiir. or uvcu tiw tiuieis. 

The articidar inflaniumtiun, althmigb the part of the ditKaau uhlcli 
causes the j^atCMt diiK'oiiifort to the jxitieut. in yet, aa it aeldom produces 
after* juencea. of coiii]>ai"fttivpIy trilliii;: inontent A ftw more iui- 
portaut feature is the heart afiwtion, w hii-h is* so coniinon an espresmon of 
the mnlady. Intl-tniniation of tlio tihrou>; uiniutiitru in and around t)ie 
heaii ie an essential part of the <lis«afie, as it attacks younp; persona, (ut<\ 
moat not be re^ardiK) on a mere casual complicatioii. In twceptional 
eauea, indeed, a cliild may liave rheumatic! fever nii<] tJie heart may esenpn ; 
bat in rheuinntittm all the libroiiH Hti-iK^tures of the body urod not b« af- 
fected at oner. The patient niiiy have iutluiiimation of onu joint imd 
not of another ; the right wrixt, for titstancc, may be afTcc^tod and t}ic left 
may etieape : one le^; may ho crippled and the otiier mound. So the di^eaae 
may attm-k the joint» and leave the heart alone, na it may attack the heart 
ua spare the joints. Tlic youiij^er the rhiM the more likely is it lliat the 
dinrnnii will fi»t«n upon the heart lo the exclusion of tlie nrticnhitions 

Th«oe(tivreDe«of rbeuu]atirindA.mnnatioD of the heart and pericardium 
is not At once announcoil bv any strikinf; rlipinjre in the Byniptonis, or even 
in the aiqiectof the patient. Indeed, it is matter for sm-prise iiow completft 
in moflt naiteH it* the ahft<>n«e of all external indicntinnn that »o imjxn'l.'Lnt an 
addition has btn-a made to lii» ilhicK)<L Often tht- only si^u of implication 
of these or^^nns ta ck-rivod from phiiticiil oxaioination of the cheat. 

In rheumatic inflammation of the perieardium there is in onlinarj- uaiiea 
n»ither pain nor tendeniesa ; we notice no RpiM<iiU huiTy of breathing or of 
pulse : tli« henrt's action may be irre-^dar. but there are no pidpi1»iio»s ; 
ther« ia tittle change of colour iu the face : and, imlexH tbi« jmnt affection 
be severe, the temperature may be only modenitely raided, or may even be 
uormal- In e^pite, however, of the absence of aytnptoma, the cliUd looks 
ill ; luid while up and al>o\it— a.-* he usually is before coming under the no- 
kioe of Ihe inedicid iittcndaiit, if the nrticular inflammation in not severe — 
hit) countettance wcan« an eicpressioii of distress nhicb quickly attmcta the 
attention of bin frienda 

A little girl, aged three yenra and a half, wb-i admitted into the East 
ID d^dron's Hottpital. She had hml a alif^ht cough for a fortught, 
and ma said to Uari' looked ilL On exutuimition, tbeix- \vnt< found <hd- 
nw of {lynmidal shape iu the pru>cordial region n.-uchiu{; upwards to Ihe 



atfnio-ckjudr&l clanculor, and to tlie rifrht ob far » oue ilugi 
ultli Im-ond th« right edge of the stenion). Tlie aneX'beat of the 
■was Ijtihiiul the fifth riU. BUghtly to the inner sidf of tlio nipple liDe. A 
iaiut impulse wiut fell all over tlia pnixxH'dtuin. Tbv lioart-souudH were 
^uSIeil. iiiid a Hoft dotibk- rrictiuu-Muund wu henrd nt the- Ijime. T\ie rliild 
■ eouipUiufd of no imiu. Th««re van do affectioii of the juintn. The otiivr 
or^VM werft healthy And the teinperatuire waa uormu. A vreek after- 
awards it WRB uoted : *' The cardiac dulu«M is as nt List report, and therfr, 
the same friction to lie hfiird over the unxxtrdiol re|hoii. Since mA 
D the child has IukI no svmptODia, anu the temperature has been 
IIt fnibiiormsL Still t]i(> iMtient ]Dok*t iU, aiul there is a distreued ei 
premion ou the fore even during sleep. Is Don' (^ v.v.) Ij'iDgmsleepoD hvt\ 
Murk, inclining lu the loft side. Pulw 88, n^tiliu- ; rcspimtioii 28, nares iioi^ 
meHng. Souie tilij^'ht liTiditv about tlift tuijuth and under the mrea. Gan- 
wal pallor of facf, vith a fiiint tinge of pink on her chedw. Lipa mtlier 
paltL The sQpeilifinl vpihh are visible over the sides of tJie nttck and the I 
,Mol» of the hnndu. althouf^h uot(p-««tly nnlnrf^ed." AtUr a few wmIik the 
nh>'8ical foRns of Uie heart hcouue aormol, and thi- child'x hi-Jillh ytoii per^ 
fectlx' reHlorod. 

llieabore iUuittnitcB ver\- veil the general appennuioe of a child who is 
tlie mibjet-t of )>encnnliiis. In the hirge iutijont> of cases, althougli he may 
look ill and be liuiguitL yet if thert- ht- no joint nlTwtioii, he lunkett uu q>e>J 
itiid foniploiiLt. Aii exaniitLOtion uf the chest at once reveahi the CMtse M 
the indisiioKitioD. ' 

Still, it is ri;f ht to nav that in exreptional cohch cnich moreBerioos^ymp- 
inniH may be noticed. Ther« iiiay be tiiniultuniis action of the hewti with 
grent dyKpiKitft or c\i-u otthoptiir-a, luii! luidity of the foee. The eount*<;i 
luuice may exprrHe the utiui^sl tmsicty. and the rctrtJesam^iui may be estntaUk^ 
There in iiBually, oiso. some puthncKH of the face, luid alijihl but general'! 
cedeniu. I'lie fjravily of these fuses is probably o«ing to tlie participation 
of tho heart subiftaiic-e in Uie iutlauiuiation. Again, in still other cases vt 
find sytiiptuniH all poiutiu^ to the brain. Thei-c is high fever, with bead- 
nehe and delirium (see page 1&9), Such coses are, howerer. chietly inter- 
esting from their rarity. They occur very aeUlom even ill hoiqiital prao- 
tice, and are cliuical cui'tonities which for practical purfmnes may be put 
on one aide. 

The beginning of jiericni'dial inflammation ia indicated by a more or 
less loud nib of (riction docompaiiyinji; the sounds of tlic heart The r\ib 
is beat heard at tlie biMc, tm<\ in double, the systole and dioHtole being no- 
compaJiied by a distinct catch or Mcmpe, which is very superficial, and con-, 
reya the impreafiion of being gencrnled «t ii poiut neoi-ei- to tli<: «ij' than the ■ 
Bounds of Uie heart tiieuiHelveti. Ji)veu if there U- at tliu nninc tiuic tm en- 
docanlinl iiiiinnur, tlie frirtioti sitiiml can be iu lauat aixeH readily eep^ 
rated by the pnu'ti(M>d oar. through its liigher pilch and uiore euperlieialiJ 
character, from the lower pitched nud luorc <Ieeply sounding uiHi-mur geiie- 
rated by tlie intiaued rnlvc. A pericardial frirtion-soniid ia not, however, 
alwn\'K liigh pitched, and even its miperlicial character may not be su de- 
ei^ledl}' inarke<l as would be exj^eeted. In certain cafles a load blowing 
sound is heard, which is imlistinguiahabtc by the car alone from a Bimilor 
sound of eudocanliol ongio. It« luet^hauisiu must he Uten decided bj, 
other couiddenitions. 

At tirat there is no alteration in the pifceordial duloees, hut in a day 
or two, 08 fluid is jiounMl out from the intlamed serous membrane. tt« 
limits (if the heart's dulnusti ore cxlcudcd. At the saiae time the ]ioHitioD 



of the npcx-beat of the he&rt is raiBecl, aod the csnliuc iuipuluc in foublcr 
than befuiv. 

A little girl, aged scvoii ycnm, had a niilil ftUiiok of rbuumatbim foU 
]ov«il by ch<n-ea. Six moutlw ftf l'Oi-iv-iir<U the cborcic moveuaeutti returueil, 
bdJ (die Ailmittcd into Uie EoMt London Children's Hospital. Ai Uiis 
time tho lu>nrt'« npex wax noted to be bcAting l>etween tli(> &ttb aud eixtli 
ribs, one-foiirtli of n& indi outride tlie uippU lino : and a soft syKtoIic 
mtinniir was heard nt LUtH spot. After bciof; a fnw diivB in thd hospita], 
the cluld's teinjierature romi trum uomuLlto 103.S''. mul a dnublo nib wua 
del«ctad over tho pnocunbiU rc^rlon. There watt olito n pat«b of ptieumrv 
nia at tho base of Uic rif;lit iuufi:. 8onic duyn uftt-rwiu'dit elTuinon vfna 
fband to hare oocmrctl m tin; pcrifanliiim. tlic Uiuit^of tlio beai-f'sdiilneaa 
were (ntendei, and the lienrtH apax ivmh raiwd to It^tween tlin foiirtli nnd 
fifib hl>3 ID the tiippic line. The double h'icUon wob ittill lieiuril- most 
distinctly itL ILv k^vrl of the tliiiil let! eterao-choiidral urticulutiou. 

If miit:h lytiiph xu<l little lluid W thruvru out. th« luind iibK-ed ujKin 
tiiB pm^ordial region uiu oflou detect n di^tini^t fremitus uitb cadi beat 
of tb« heart. When a, <:i>usiderable quantity of fluid la effused into the 
pericanliuiu, the restiltiui; aiviti of didneafi 1.ik?n the nlmpe of tho coutuin- 
tog sue. IL becomsH triani^ilnr or " ]>Traniid»l "* in form, with tlii> fipi^x di- 
rected upwards towards tho top of tlio etcntum. A moderate efltitUDa doea 
not pivif lit tl>e frirtion-soiuid from bt^in;; facanl, but the nib becomes lem 
iuteuse and leitii crifip than before, and tlie lieart-Honnds are inulHed and 
diHttnt. In ^rcflt <>tru»ion the cheHt-wall in the cnrdiiio rogion may bn 
bidi:ed. and on ciirtful iiiispL'<.-tioii thu cya am often <lctvct a distuict 
uiKiaUtory raovcmi-nt with aifh beat of the heart in tlic iuter»istul 


An uuport&Qt distiuguishint; mark of pericardial friction ir, besides ita 
mputiriid ebiu-ncUtr, the trrflf;ulnrity of distritmtion of the eoiiud. EikIo- 
flftnlial munuurt arvi cAiTic-tl along nitli the btixid-ciinrent. IVriciinliid 
fiii-tJoiia tnay be limited to n atnnll nn^n, or heard cquidSy loudly over the 
whole pnernrdtal re^on ; in either ciura they do not follow tlie rules 
which ro^iiliite tlie l-rangmiiision of heairt-murniiira. Fnrth<>r. a ]>ericaidinl 
mb is iii1«uHitivd by )>ntB8uro, and is heard liottei- din-iue^ expiration than 
when the luiics are expanded. A» tbu fluid and lyiupb Itccomc absorbed, 
the liinit.'i of dulneat |*ntdnall7 return to tlicir former (liuieusionH ; iiiid the 
fnction aft«r a time becoined fiiinter aud fainter and praduiUly diHuppeant. 
If the (ymph has been e^nded in large quantity, ndheaion of the pcnt-ar- 
<liam mar tako pluou. L'nlcMit tlirre bo uhto tullirsioi) bi-twL-vii the in-rit'or- 
dium and the luijac^iit pleura, there m-e no physicad sifinaby wbiidi ibia 
condition can be det«<?ted. If the pleura niiJ jK'rioarv^Uum be adherenl, 
the iutvrooMttd spucu ourn^-Mpoiiding i'} the apex of the beart ia depressed 
at each iicptilw. Adherent penciirdiuiu is generally followed by hyjier* 
trophy of the ht>ai't. 

The fluid in pericarditis sometimes becomes purulent. The »Hpf)»- 
raliix fonn of jtencanlitiH in inor^corumnii in caHe.i where the iuflatntuuiion 
has ext«Ddoil to lh» ])rrtcardiuiii fi-om tiit* plciim ; although it may no 
doubt also occur without the plpont hnTinj; Wen preriousdy aflTeeted. In 
the cosBH of this fonn of periciu-dial intlanimntioa wliich have coiue under 
toy ikotiee, Ut^ patienta liare coinpl&iiied of pains in tlie <;heHt or vpi^^ae- 
tritiiD ; lhi> tempemture lias been high nt niKht (10:i ' to 101''). with a {jar- 
ttal moruint? rmuiiaiiou ; purioardial friction Luut dieoppeare^l early : ab- 
•orptkm of the elTiision. if it luul becuo at all. has been nIow and iiiconi- 
fla^y and tovrards the end of the diaease alight but general uKleiua huH been 



noticod without any albumen l)«mg diseovered in tho urine. Theiie 
uliuottt olwa^ft eod fatrUlj-. 

WbML eodocanlitw otcutr, the valnilnr lesion in indicated at firat lir 
no external signs, aq<I can odIj- bi! disoorarei! hy physical examioatton. 
Wttb tbe &t«tbo»cop« wo hoar a low-iMtctxyl soft niurnmr at Romc notot of 
tbe piircordial mirfncc, indicatiug, noconliuc; to it« tutu and rbytlim, ob- 
Htnirtioii or incompotj>nc» of one or anotlwr of the cardiac valrao. The al*| 
fcctioQ of tbe vnlxo may bo accompanied hy iucreaaed frequency of 
puUe and Monw pulpitatiou ; but wUile tbc potteut is at rent in l>bd 
Hjiiiptotnit are very B^icvptioual. Tcndi'mciw in iicv<^r prr-ni'iit, and il is 
niro for the child to complain ol pain or uuciuuufSH about theL-beKt. The 
val^-« aiT<!<:l«d is most commonly the nutral, oltiiougb the aortic setuilunar. 
volvDH iLTv K(>ui*'liiiieit iuflnmed nloiio, or in conjiuiotion witli it. Tlie ie-' 
iiioiitt tire iibiiost invariiibly Uiiiil«d to tlie l»ft sidfi of tbe heart. 

Kiidoconlitis may occur wilbout im|)li4<fttion of the pc-ricnnlinm, or the 
two It^ioiin may be cnmbincd. In tho latter case tbe eudooardial marmurj 
may Iw completely maKWf d by the fxtt^mal friction-saund, atid mar only ba^ 
diocovcrt'd tix the latter ttiibsidt-^. If niiaccnni|taiued by iiidniuiiiation of 
tlie pcriainliuoi, cuilocarditiM, ultkougb a v(-ni- »>crtouH miKfvrttiut.- as rc- 
ganlH the future of tbe pnlieut, adils little, if anii'tbinff. to tbe immediate 

There ia one accident which Bometimcs ocrurs oh a direct result of en- 
docanlitift. The vegetations on tlie inflnnied ralve may undergo disiote- 
gration, nut) minute particles) 8wept away into the general oirctUAtion maj 
become anf>»t(^d in uio small artvties of a distant or^^an. lJlc«mtive en> 
docarditis is not a commoa diBeflse ia cbildrci), but it i» occasionally met 
witli. This conipUcAtiun (fi^es rise in symptoms wliich may be lyihtnteUJ 
for those of pywmia or of continued fever, no cloHe somfctinies in the roJ 
aoniblftiic*^ They are j>artly corhtitutinnnl, owing to aibiuxturc with tbe 
blood of dccayiut? atoms of ort^amc matter from the dieiulct^ratln); valre ; 
partly local, from eiubolittma whicb interfere nitli tbe fuucUou of apecialJ 
orgaua. Thus there ia hi^h fever with marked reuiisHiona ; great wejib-' 
nam and proatration ; a furred dry ton^iie ; often aickness, and perhajM 
diarrliura, tliimt, anil anorexia Tlie pulse ia timalt, mptd, and wcuk : the 
breatbiug hurried ; and tlio child i^nulually bocomEva restless and deH- 
lioua, or drovmy and comntoec. Tlio IocaI symptoma an* derived from tlie 
organ or or^puia, wboac fuot^tion la interfered witli by arrest of emboli in 
tlieir minute arteries or cupilliries. TIiub, emlmlitmia in the skin produce 
peteeliia) from minute extravasations ; in the liver, swellinr; nnd i>erbapu 
jauudtco ; in tbe kidney, albumen aud blood in tbe water ; in the spleen 
awelUtif; and teudeniet^ ; in the brain, parnlvfiia ; orif from Hmall dimemil] 
ated emboli, iKtudm-he, delirium, uud coma, without special interference^ 
mtb motor functioiL In nil tbt-se ciutes examination of tlio heart rcToola tho 
sigus of valvular diAca&e. The rnaeti ^'enemlly euil fatally. 

The pleura ia often aflectad in rheunialiriiu. alone or ia conjimetion with 
the pericHrdiuni. Pleuriqratid pericarditia may occur simultaneoualy, or 
tliu iiiHammittiou may qiTMd from ODe menibmne to tlie other. \Vhen 
the two diseriaes ui"c present together, tbe iiitlanmmtory proceiKee in lb« 
two Mtufttions may be perfectly independent the one of the otliei*. The ef- 
fusion ia the pleura may be purulent, and that in tho pericardium aeroua; 
or the pericardium may contAiu pus, and tbe pluura pureaenim. 

Alittle boy, l^Jed six yeaiii. died iu tlie liwt London Cliildi-en'a Hoe- 
nitiU of pleurisy ami pericarditjs. On examinatiuu tbe right lung waa 
found odbereutto the pericardium, and partially to tbe cbeHt n-all. It w»a 


eo&dsiuted and toiif^li troui prcwture, antl the pleura oi tlmt side contained 
K Lnrgv qiumtitv <>f r\eai duid. '[lie |*ericanliiiiu vrntt iKlliei-^ut to llw bciii't 
iu ptac«8, and in ttie xnc ni'i-it about Ino ouqcm of tliick jxul Iu tUu caiM! 
tlie Uluesdhad beuuu uitli Kickut^SK luid paiu iu tlie sidv, fuUowed bv cough 
— iiyiiiptomtt wliico poiutcd to pteurisj- ; and tlu-«e w'e«kfl aXt«rwar<w, wLeu 
the child fintt cnrae under obaerratioii. tliere was ^i^'lit but ditttiuH cun* 
tntction of lt)« right Hide, shown by lou-drin^ uf tha )ibould»r aud aiifile 
of Uie scapula, with dtEtinct carving of the Bpine — the couvexity to iJie 
left. Tbeite hi^uh, taken in ronjuiictinu with the liiHtor>, aeeiiied to iiidi- 
cute that tbt* pleuriftv bad dnl^'d (ruiu tho )iet;iii]iiii({ of tliu iUuem, luitl 
that therefore, if it (Ud not <^vo riMt to t)io ptrrirAnliliK, \ra» not, at nn^ rate, 
necoodary to it. 

Pneuinonin i«i not n,r» in rhftuniatic lever, and may occur in coujoDo 
tifm with ptcunsy or iiulr-pfndciitly of it. A mu<rh rarer lenrm is nicnin- 
fOtis iLffcctiitt; the luviubnuius at tbu {.'vnvcxity uf tbv bruiu ami tboM of 
the sj)iue. Tlu.'so eamee ore ckoroctciTwcd by liif^b fercr. heodikche. and du- 
Urium. fitill, wb must not suppose that in eiery iuatanoe where such 
symptoma occur in the cnurtKi of acute rheumatism thej are due to inSiuD- 
maUuu of thu curubrnt mi-iiiii^«tL Many <.7<8e44 nre now on record ia 
which thew syinptouia have been pre^eut, with olliHrs— aH {^iciiiliiig tn the 
bead aa the seat of the lesion, ond yet on diHsectiou uf tlie dnul bodr uo 
aigm of disease ltav« been dtucovoml within Ui« crouium. Dr. I^Uiam 
has ilescribcnl a cnse of thix kind which occurred in a little 8c)iolar at Christ's 
HoqiitaL Tliv buy hiid hif^h (ever, hMulnche. <I(>liriuut, and conx-ulsions ; 
and dieit iu spito of energetic treatment direct«d a^ialnst a euppoeed meo- 
in^tia KMUuination nt the body diHclosed no diaeaae of the brain or ita 
toembrKnc* : inatciul, th«ra wers all tho ngna of a ssrero paricarditifl — a 
^^Mj—a whioJi had not b««n so tnncb aa msspwi«d during life. Trotis- 
sean bttlietraid thui fonii of "c«rel>ml rheumutiam," which leavca ua trace 
of intmemnial inflaiimiatinn behind it, to be a neuroftia dependini; upon 
aome Bucli uiVRteriouM riiixlitif at! on of nrrv€-siihfitano« as is believed to oc- 
cur in liyntcria and tvtanuik Tbv symptoms may, howvvcr. bo fxplained 
more tiiuiply by utUibutiti^ lliciu merely to the elTects of hyperpyrexia ; 
and Uiis is the view comuiooly sccepted in the prenent day. 8uch a case 
has never come under uiv observation ; nor ha<>'o I ever seen a case of 
rbeuDuitic iritis in the child, Jior uf peritouilia otwurriug iu the course of 
■cut* rheuntatism. 

P«ritoniti» may, howeror, be simotated by rheumatism of the abdomi- 
nal muscles whicii sometimes occurs in children. If thiH be MTeie, tbara 
ia trademess on preasure of the alMlnmiunl wall, the child may have on 
■MMuaoce of groat distress, and luny lip in Iwil uith his knees dexcd on 
hia Bbdomen, ns if he wen* iT-nl!y siiff(}i-JU(; tnna inflAmmation r<i the peri> 
toneau. The bowels are nsuolly ronlined. These cssea miiy bu rt-iulily 
distinRuished by careful exxminilliou. Tlie face, nlthou^li often (listreBsed, 
baa not the haggard look which is so chnracterixtic of jii^ritouitis ; there is 
little or uo tenaiou of the abdominal wiill ; tho mitunU muj-kiu({8 ore not 
loat; the tenderness ia not extreme ; the pulse is soft, couipmudble. and 
of moderate iiuickness, not rapid and burd ; and the temperature ia uoimal 
or only aUKhtly elevated. There ia generally great aci^ty of urine ; it is 
•cwity anil hig)i-a)Inured> ami its passage may cause some Rcaliliiig. 

Torti<^xiIlis |stiff-u«ck) is sometuues a consequence of rheimiatittin. The 
diMAM may nffect the muscles, eroecially the stemo-mostotd ; or may at* 
lack ibe fibrous ligamenla uniting the veitebne. The nervous s>-Htcm, too. 
w^ miEer- NeunUgis has been notieed in some children ; and paralysia 



of the must^lPK of on'? side of 11i« face ma; bp pmiliircd bv rhmimatio in- 
fliiiiiiiiKlioii cf tlie rtlieath of Uie tadal Derve at iUt jioint of «xit from the 
buuf. ^lurforer, there is nn evident coaD«rticiD between rbeamatiKm and 
«boi-ea This iiiijKirtAni subject will bo ransidered riMwhtre <mc Cliort-a). 

A peciUi»r msuufestotioD of rheiimAtL^m is sometimes fouiKl in chil- 
dren. Tliis vraa &nt Dotioed by Meniet, atid is clinructerized by Hnplliiiga 
TorviiiK ill iiunitrar nnd dza wliirh npjx'Ar in tbe tpiidniia ami thnir nheatbi^ 
aaA in otUer fibroiie structures 'wUi(^ll lie cLow undvr tho Bkin. XIdw (bvy 
are seen nround tbo pnteltaivnd tlie innUi-oli ; on thv H[)Uiimis proccsiCH ; on 
the teni[)oral ridp:<>. and nn tlie KU|wrior cum^ Uno of the occiput. Tliey 
ttTf Torx' hnrd ; orf lUTonijuitiicMl by no rcdneo*, tenderness, or pain ; aro 
somctiiuca movable : luid ditsiippvar uft«r a time Bpoatatieoualy. Thvj 
are composed of saiaU uiai»ai of loose Gbrouit buudles, and arc verj- va»- 

A little giri, nearly ten ^eare old, wa« under my t^^re in the East Lon- 
don ChUdi-en'rt Honpitid for au attark ol rlieuiiiatir fever compUmled wilJi 
choreiL -Sli*- had a harsh systolic luumitir nt the npe\ of her heart, whicU 
erKleiitly du.ted from n previous attark of endoeardttiii -. but Iho npux-beak.i 
vrm not dii3]>lat-€nl, nor were the normal Utml« of the heart's dulneBa ex- 
teniled. In Uiis child fibi-niis ondulen were found on tlio Kuinous proceaasB' 
of tlie Tcrtebnc, the proiidnencGs of the scapula, the liead of the raditH^ 
th« tADdonn in front of the ripht aokle, and the hark of tlie rijiht luuid. 
Tbo notluleti vurifd iu &iz)e from a split pcu to a Urge marble : Uicy were 
not t«uder, and ihi* akin orer Ihem vws iiut itdhureiit. Wliilu the child re- 
mained! in the horaiital ber temperature never at any time rose n))ove lOU". 
The ttwelUn^ (pwiually dimiiii»hed iu size, and by the end of tlie uoutJi 
had almost romplet^-ly disappeared. 

l*hc dtimtioQ of Uie rbeunmtic nttack is much longer in iome children 
than in otli«rs. It may bs Tnrioiixly ertimatwl awxtrding to tbo method 
upon irbich the reckoniofr is amiiuctcd. If mc talce into account merrlr 
the joint nfTection and the penend symptoms, the diw^ae may be considered 
over in a few daya \ child amy be titkcn with high fever, and oomphtin 
of pain in one or other of his joints, whi<:h is fouud tu be n-d, swollen, and 
tfiidnr In twenty-four or forty-ei^bt hoitnt the articular iullumniation 
Riny lid nt nn end and tlie tfliupcraturo uormnl. But it does not ftillow 
that llie diaoase ifi over ; and if w« nl onM begin to treat tiie child as a 
con\-aioecent, w» nuiy (iod reason to regret our precipitatiou. Serious iii- 
jlamuintion of the pericardium and lining meinbraue of tb« b«qui. is quite 
comptttihle nith n normal teoipemtare ; and those iutemal lei^ions may bo 
only beeiauiug when Uie external tdgua of the diKcoHc are on the wane. A« 
it 18 on^ iu exceptiiiual cases of rlieumntic fever tltat the heart doM not 
siiflTer. and as the tuildeat attack of perintnlitiH is iteldnm over befon n 
w(f-k hoM p;one by, tA^ht or teu diivH luust be couaidercd tbc Mrlicist period 
at which cQuvnlcaeence con be said to begin. 

In other maeB, if there are frequent relapxea, the disease may be pro* 
loii^i'tl for many weeks, the iulliuumntion lennng joints and reluming to 
Ihciu with wearisome re|>etitiou. aiui the iviieanbjil inflftninrntiou Tvaxing 
and wanuig vrith nmilar peniixtenry. In ttiis way nn ntln4-k iiiny be made 
1o lust rix weeks or two montha It is, however, only rigid to say Uint 
Binc« the introduntion of thii aalioyUtca thaae casea are much rarer thau 
they uaetl to be. 

Altliout^b tlu< juint nffccUon iu rltcintintisai in nxuallr an acute ditteaso, 
and ceases when the attack Is nt an en>I. yet tliia is not alwayn the case. 
Chtldreu with strong rltemualic ttmdducies, and who bare bad eevend at- 


tocJut of rb(>utnatio fever, mar pomplum of wanilering p(unfi in the back, 
neck, ADd loiiiK, and of tnLusi^nt iltneomfort ami ntiffneaa in a joint from 
time to time, ei^MM^udlir iu the Tiu-iii.Itk> »eneoii8 of the year, witliout hjiving 
to take to th^ir beds. Iu Biii'ii |iiitiout8 tlier« is gt<ijier»1 irnuui-meot of 
hf 1**1, appetib} is poor, nai\ nutrition iu unuitit^ctun'. Xlie child is 
oftCD exoeasLTcly uerruua, sleepii badlv at. night, and m r-lmugealite in l<:<iu- 
per. Dr. West lian coiiDectetl these 8yiiiptoiii» witli the lithJc acid dialLe- 
ftifl. Tliere is no doubt tlukt sueb cbiltlriiu oro 8t]bJ4ict to sandy depoMtM 
iu Uieir urine, aud to abimdAnt Eecreliou of mea. 

Diagnotis. — Wlien the joint affectioQ i» well mnrkpH it can ncarcel^r 
be miaUkoD. Au acute artioidfu' iDflammation vliirli fli(>t( from joiut to 
joint c9iprieioiisl,r. is nccotnpdntod hy redness, swdlin^, nnd cxtrotno t«&- 
demesa, and in n ilar or a couple of darn baa paaeed compktelj nwsjr 
from the joint first atta^kt^cl, to run the Bame rapid conise in nnotlier— 
■aehadtMOM cod only b<i rheiuDRtisnt. R«tU rheumatic joint aflocUons 
BTBTerytiaiiaitory. BrodnesM, pain, aDil HweUin^^pcnuatina joiniminmaed 
to be rhetunatic, we may imsiiect atxonfjly that the true cause of tbe lefoon 
haa vet to be disenrercd It is ofton ciiflioiilt to fleddfi the nature nf the 
obeinire paiua nnd ntilfnesses from which wjum chihlren suffer. The ao- 
caUed "growin;; pnius " are uftvn rhe^iiiuntio in their ori^^ ; and if tbcj 
oeeur in chiltb'eu of decided rheuuiutic family tendency, sliould be re- 
garded mtli extreme snspicion. A enreful esaniinntion of the chest will 
often clear np oliscurilv, and it w unfoTtuiiat-oly too uomiuun to liml aerioua 
TBlvular or p«rican1ial iiiiitcLief lUtmucl-itL-d with a ven,- trifling amount of 
■rliculBr or even mueeular juiiti in youii^ Hiibjet-tH. A to-iin<l-fro friction 
aoond over the prsecordial re^ou, if detiiied. m verv Hu^pii'douA in itself of 
perimidial infLimmation. If the rhiUl Inijk ill, and (-s]N'cin.ny if there be 
alitn increjuee of tlie heart's dutuoKM, the f'vidcnnt> in tLs fuvour is coiiijtleto. 
A faint double rub at the bnse of the heart i« not in itself »uffici«Dt to ee- 
tabliab this aHiduaion -. far such a friction mar be produced by Bhitht 
rougboess of tbe pericardial surface, from prominent veftneU or other cause, 
when the memhmne la quite free from intliimmatJon. 

DuluetM of p>T:\mi(hd shape in tbe precordial rc^on, although very 
■i^ciouH of pGricanliiil rfliiaion, is not conclusive ; such a dulness may be 
produeed by a msss of enliu'^ed glands in the nnterior wediaatinunL Ex- 
tension of 'dulaeM to the left, beyoml the point nt vhich the apex beats, 
is aaid to bo A poaitivt- »igii of i-lTasiou. The tticrtttHO in the (lull area 
when the uitienl i^ placet^! in the oruct pusitiuu is often abuent : when 
present, it is, no doubt, an ndditionid proof of fluid accumulation in the 
aao of Uie heart. 

When the tluid becoineM puruleut, aa it may do at an early date, the 
nature of tbe contents of tlie sac inay be inferred from the variable 
iempetature, the niercuty riaing every nigbt to 104^ or 10C°, nod sinking 
ID tftp momiug to the Dormal lerel. or even below it ; the fliirly subaideiuia 
of the friction, altliough the amount of the efTusion remains iniehaogod; 
tbe stAtionary dutracter of the dulaess, ehening want of abeoi-ptien of tlie 
fluid ; and the appearance, after a time, of more or leas general cedema 
without allraniinurio. 

Oil Accnuut of the fro(p»«ucy with which pericarditis and pleuriBV are 
combineil in youuf; children, nc Khould never neglect to make a careful 
wotminatkin of tbe heiut in every rase in which we have ascertained the 
•natence of pleural inthunmntion. PericanUtia, umlor theae circdmstaneesy 
ia Dol oaay to detect, ua the dulncrsa in the [irioci^nliol region ia attributed 
to tlie eSiiiBion iu iba chc«t cavity. Uukiis, howBTCr, the pleural efftuMQ 


be very great, the pereussioc now ia. the infra-rlnvir:il»r i^epion in 
diflVtront from tlmt nbtainvil t&t])« pnecordia. If, tlicrcfon^, wo diul oook' 
plete dulnct<s towards the upper port of the Htomum, uod u iauiy rcttouant 
or wocideuuote WlnwtJie claTiclenearthe acrominl niigte, vte may struDf^ly 
Hii8pi>ct aociuQUliLUon in tho poripfutlinl sac. FricHioii orer tlie lieart may 
tbcD bo f^iicTally board on cux-ful nuscuJtntioa. 

A difficulty BiHnelimea oriiscii in iJieiw caam from a plcunU (ricUon of 
carduc rhvthni bc<iiig heard at the limiUof thi> pmcardiiiiu. TbiHiKuwinK 
to tb« a(!tion of Uic lic-nrt ciuuing n movement bet wtren lhi> adjaceot pleurat 
8Urhc«B. Ill tlicKo vnBCH if tbo child In- old vuuu^'li, ur siiffioieiit^ attii^.^ 
ble, to fuUuw direc'tiuDH. we iibould listeu at Ui<> HeHl of frielion wm]« th« 
breath is held after forced esuimtion, and if Uie rub ceaso or be heard 
ouly at tiaa «]>ot, it in probably <tue to the cause referred ta It ia D0( 
always poMsiblit, however, positively to exclude pencaixlitu. 

If ne hear it blowiug luuruiur at the ajiex of the hoort, th« qtiestiOD of 
T&lvular <N>ti]peteuce has to be cousideml. All blowiuf^ murmurs nt tbe < 
apex muflt jiot be taken to indicate re^i^itation, nor, itidcod, iltb they S; 
p)%(itive tuj^i tlint tlie endocarditiiu is iB&tmeil nt all. The raiirtnur mayij 
be tiio (\iMs«^|iioi)<!(t of ref^rf^tation, of rougbna-w of tbe iiUvo or cfirdine 
liuiti^, of uiiictuic diUtatiou of the rcutriclc, or of uiorB abuonual tcusioD 
of a heidtby vulvc, and t bun; in nuthiii)^ in tbt^ qunltly of tLv Huund to Hbow 
to which of these t-aiiseH it may be properlv assimied. If, however, tbai 
»»cond sound is evidently intensitied over tLc pubnounry ftrt<-iT ; if tbft < 
niiinnur in beard at the angle of the 8cai>ula ; and if, will'i a fultcoutrao- 
lioii of tbe left ventricle, tbe pulse U feebl», small, and irregular, vrt tsay 
confidently pronounce the niitnd vnlve to b« iBsuHideiiL Still, regurgt- 
lataou may take place without ginnt* rise to these signa.^ Thei-e/ore, in 
most caaes tve must reserre a poaitiTc opinion, and wait until sufficient 
time liHR elapsed to allow of nutritive rlianges taking ploee in the veM of 
tlie lic-ort. If tliere be no diiiplaeftmcnt of the apcx-bcat at the cud of 
twlv« montJiM. wo muy be satiatied that the cause of the murmur is not 

A reeent njurmor is wry soft in quality and of low pit«h. After being 
in exiBt«nce for some months it booomofl boreher and its pilrh ris«s. if in 
acnsc of acute rheuiuatiam ire hear a harsh and loud endonmliiU murmur 
at Uk^ njiex, we may be sure, whatever its mechfmiam, that it is not of ra- 
e^t origin, but iaa roUc of some former nttack. 

The <liaguu.iL» of ulu<irative eudooardilia has bei-ti ulready RufRcipntly ex- 
plained. If we tiiid that a oltihl. who haa lately mflered from an attat-k of 
acuto rhoiitiiiiliBiu with ciidofiirdilis, remninu ftrcriah, with rapid elorationsi 
lUid depnttwions of lunipen^tiu'ti, such as are characltirittliu of auppurataou i' 
if he piuiH ijnirkly into a typhoid state with i\ry browu tongue. Iukh of ap- 
petite, hurrittil l>r«nthing, and ripna of great proHtnition. wo should rus- 
peot the proMDce of this complieation ; nnd if we find eTidenc« of cmbol 
Ltuna in apeoinl ar(:;iuiH, our suspicious ore aufficiently nuilinnetL 

/Voj/noKUL^Tlie inimodiate proguoidH of acute rheumatism it; seldom 
otliorwisD than favoural>le. Ereu the existeniN} of r-ndonuxlitis and inJlam- 
ualiuu of tho fHtricardium cniiiiol often h« reganlcd as ginng riao to nuy] 
fear of immodiate dangrr. Still, it t8 well not to speak too positively in 
pnslioting a favourable isauo to the illuosa. In ncule i-)tenmalii4m— even in 
tho mildest «wen — Ihei-o ib a tt^ndener to hy)H>ruioAis : and the rapid for- 
mation of a clot in the right Trntri«lv of the heart or iu the ptilrooiiary 
artvry may be a riiuai' of suddi-ii d(*:dh. In aonir inittmicvs this distress- 
ing acciduut hnjipoUN quito uiivxp«'et4>dly in a cma wliieh u ronuiug it fa- 

voomblK I'otirgn, and mny orcm occur ot a late perioil of tL« i)is6&K« after 
conralvticcnco boe soomcj to Iki e»tabliHhed. A^^iiiu, in rare caaea, pericar- 
ditiH in a raiusc of deutli. WIici] tJie eiffuwd duitl is or Inecomes jiunileDt, 
the danger is grent ; ami fen- ttunh cnscs nx!ovf>r. 

The ultimftte roniuy]iicnoeii of mi nctnok of rli«iimatic fovor niA^ be vory 
HOrious, for tlit^ liirf,'ti luujoritT of cruscit of hriLrl (UBrafie cmi be refeired to 
ihU taust. I5ul. iLH ulrt'ad/ i-emaj-ked. Uie uiecbaniHtn of heart-niunnurH 
issovarioum that the mere exiatenre of a blowing nound at thu npoic of 
tbe heart ir uo iiidiuation ia ittfulf Hint Hun<>us cvumMjutucuiitircto Ik.- ap- 
prfht'iulod. If llie diilil bi' ii«>(<u diiriug uii atUick, or vhile the isunnur 
ia still recent, it im impiiHHtble t^j tmeak wiLb certaintj as to tlie gravity to 
be attached to the phenomenon. If, after a time, we discover ngus of di- 
lated hi'pei'tro|iby of either veutrick-, with djitplftvemcut of the heajfa 
apex, and nccoiiluAtion of tlio socoud sound at Ik^ piiliuoiuiry uu-tiliif:^ 
we iDtiy po«itively nenune Uui HeriouH ineompet«tice exista of the mitnd 

Endocardial murmnn* arising during nn attack of rheotnatism in cbU* 
ibrcn sometimes di9H])p(>iir. It iH prolmbln tfant in iill thi>sn ciwps tJic mor- 
bid aouod was generated bv oUrt mechanism thtui mlIvuIeu- iacompotenco, 
for J hare never known tho HiuH.-ultaLoi->- HuuudH t« bccoinB liL-nlthy except 
in cBMfl where the henrl's apes hiis retained its uuriiiul situatian. 

A little boy, aged eighteen month)*, witb sixteen teeth, wiie brought to 
me in Nnventbt-r, !NT1. \ few montbn previoiirtly lie Iiud woiiifd to hure 
pain and stifTuoitM in hoiiiu of hi« jmnls. nml hnd bi<&ii a little feverish. 
sinoe that lime lie luul boon >4iibJ0(?t to i)»]pitatiouH wliic-h were Homi>tiraeH 
violaut. On exajuiuation I fouixl a luud bikaic ByBtolic uiurmnr conducted 
to the secoiul right cartibigf, and at the npex a lesn loud mitral mur- 
mur. The apex-beat was iioniml. lu Miii'i>h, ISTS, I tuxv the child ogniii. 
The wcz-bent was «till in normal 8it«. The h^art-eouDdu woi'O a tittle 
mofflou to the ear, although nn murmur could ho bearrl at either the bass 
or the apex ; hot on thin occnsion no attempt was ma<le lo escite tlis heart's 
aetioD. The patifint wax m>oii for the tliiril time in Mnrcb, IHHl. He wax 
DOW ueorly t-'ight yourti old, nud of uvcriif^c hui-^ht fur that nge. Altliougli 
ratbi-r tbiii. ho was itliitcd to L-ujoy good bcultli, and never ra^mplained uf 
palpitations or of brt^atldeKanesH. The poHition of tHe apex-lieat remained 
uiudlered. The tirst sound wm mtLillud, and nftei tlie boy had bcc-n made 
to run round ilie room, u faint systolic muriniir -ntm dovolnpod at the ii|)cx. 
It could not be heard at thu aii^de ol the Hcnpiila. 

Xn this case the basic minnini' >U9aii[ie:Lred, and that at the apex be- 
canu ao indistinct that it nmid only be iletected by exciting the Iteai't'a 
■etion. WbatevAr may liave been the ctimte of the al>iionn.'il snunda flrat 
beayd, they wnm apjmroutly the couscquonoo of rhcumiLtisni. HtiU, it 
ascUM certain that there could bare been uo organic lesion of valve, for in 
tbe course nf nearly seven years no alteration in the nutrition of the heart 
had taken piaon. 

Trentmeiil. — A child the siibieot of acute rhcumntiam mniit be kept in 
bed ; the iuSamcd joints must be wrnjtpcd in cotton wool, kept in place by 
a firmly applied thmnel bandage ; and the chest should be uJmo enveloped 
in the same material. A mercurial purge abould be given to produce free 
adim of the bonclti ; nu<I totUcylate of itoila nbould be adiuiuintered ntth- 
oot uoo«cewar^- delay. Children, aH u rule, bcjir tins remedy well. It is 
•lemtional to Iiud any ill effects remlliiig fii^im its employment. For a 
child of five years old,' ten pprains of the salt may bo given cvci-r two or 
three hour9 with tincture of orange j)eel and glycerine. \VithiB tw_o_ 



or thrM iayst aometimM vitliia % lev houn of b«guuuQg Uie trefttmeAt, 
the tempenton blls. Ui« piil«« beeomcw less fraqaent, and the joint sTiup* 
toms «ro BiucK'niti^d. TL« uulHe iistiftUj* luuw iu stnitij^i as vit^U «« lo 
frcqaraoy ; and tb« dcpresooD induced br tlie action of tb« druR upoD 
tlie mnHcular fibren of the heart in HnmetimeH no Ktvnt thnt its admini&tm- 
tioD buH to l>e KiipplemeDt«d b,<r 11>e free titte of fitiitiulniitH. TUi» efivct of 
tlio rcnwdy is, boweror, lam common in c)ip(lr»» thnn it ig in Uio adult, 
00(1 I bATs nuxlr been obli|;ed to diimmtiQue ita uhu for this renaoti. It 
sometimeii ctuiaeH diHtreHBUia vomiting;, and occjiHiotudly excites epudaxis 
wbioh may be obtttinate. If, on aircount of anv of th«se aradeata the 
tl^atioeDi ba« to b« auspcuded before tlic dineotte i» completely subdvcd, 
tbo tcmpcnttun^ often riscK u^un, and tliu joint iifTcc-tion luiiy rehun. 

In a suiilU minority of the oiKes tlu> meiUoine, although weU bume, ap- 
pears to exerdae DO influence upon t^ diseaae, and erenwbea it lowera 
the ten literature and Bubdu«e the joiut affection, it seldom prevents tlie oo- 
(-iimmce of cardiac or pknirs] iulLiuimiitiou. Tlivtintt aigim of pt-ricaF- 
(titi!>t mny be notie«d wli«n the pntitut uppeiLm to bo under the influ«ne0 
of tho i-emedy ; and I cannot say that in any case the couree of the peri- 
cardial difleiiae ban appeared to me to be shortened by the use nf the sali- 
cylate. Still, if only for itit influonee in redueini^ temperature and check- 
inf; nrtieuUr inSiuuinatioD, the drugvonld )>e a moftt valuable out, and w* 
ahuiild not be doin;; our duty to the potiout if we neglected to employ it. 

In casea where the salicylate caunot be used, n-e may adopt Ibe aUtolina 
treatment, givinp bieai'bouHte of potasli iu l.e>n-(^n dci»es evety three or 
fourhours. If tliou^ht luIviMibli^, tIjL- bicarbonate may Ik; iTumbiiHrd ivitb 
qiiiiiiuti : or vre may prL-!4L*rib(; rt mixture of quinine with iodide of |x>tflH- 
Hiiiiii. us rOL>umuieuded by Dr. C-iroeDbaw. The objection lo the lUkidine 
plan of trentment \6 thftt it euoourticea the lemliiij; to nnicmia. It should 
therefoi-e l»e Hiipplement^I by tlie early adtiiiiiltttnttiou of iron when the 

eint paiiiB have Hulwided. Tim rnetlK^xl i»f treatnient adrocated by Dr. 
. DimK, which consistB in encircling the aflected joint with a thin ^o of 
blinterins Duid la a painful pmccediuR and ill-smted to young patiente. 
Tlie l^eiit tural npplii^ation i» a thick layer of cotton wocJ, with a firmly ap- 
plied fiannel hinder. 

If there be much pain in the jointa, a enudl doae of Dover's powder can 
be {;ri*reu at night (gr. ij.-iij. to a child of four ur live years old). Chloitd 
muitl. not be uis«I duriuj; the admiiiislraliuu of the salicybLte, uh it alao has 
a depredKint; etTect upon the heart. 

Hy])erp;tT«xia in not coniiiiou in cases of rheumatic fever in childreOi 
and, indei'd, it i^ difficult, to my Trbat dej^'ee of elevation of temperatni'e can 
in an orrllnary eiuw be aeeounted hypetpywxin in n child. An injurious 
amount of fever i« uxually aeoonipanieil by symptome of mental disturb- 
anoo auch bx are chnroclcrislic of the BO-caJled " cerebral rlieumafiBm."* 
If theae are absent, itia uiuiecenwiry to attempt to reduce the teni]>eratnre 
!»• bntlia; unless, indeed, tlie pyrexia persist ainl spcm to be injuriously 
uft'uctiug tliv pn.tieiit'a ntreugth. I have uc^'lt aecn a catw of rheumatic fe- 
ver ill a cliiM ill uliich I have felt it riecev^ary to employ eold. 

Tlie diet in. acute rhoumatism uiUHt be aimple. White tlie fever pex^ 
aista the child should take uothini; but milk and frceb>moat brotbo, with ft 
little dr^- tonat ^Mlea th« temperature falls, a more generoua diet may 
be allowed ; but for Home time attention ahonld be paid to the iiuaotitv of 
fermentable matter, such an starches and sweets, taken by the child. 'th» 
appeemnce of litlintea iu his water is a sure ugn that some modificatioa in 
hu diet is rei^uircd. 

Dipoetly the csistenfreof pmcarditia U afleertainecl, a bliHter ithoulrl ha 
Bpplit'tl over th^ pncixtnlutl r«giou wiihout toss of time; 1 prefer Ute 
Mistmii'; fluiil for thiti purpOM.'* lut iuo»t r^rtuiii iu its turlion, arul iutt> it 
to iiiiiU> vouiig oliiUlrea. It in at <>xtremo iniporlaace to elieck the peri- 
CATtlial iiifltiiuuation earl;, and there Ore uo meoDS at our couuoutd bo 
e1li*:nrioii3 fur tliia piiqiosw' a»a blister. In rannv cnst'H the effiisinn bc^ius 
to (li^ippntr Its Mio liliiitor riAea. If tbcro be iiiueli ett'iiftioii. aoil tlio joint 
affectiou linvc Kiibdi<l«<i, I nm in the hivbit of giWug iitrgc tluso* of tlie lo- 
ilidfl «I potaHaium, nlune, or vfifcb the tnrtmte of irou. Tbo iodide is in 
mv Dpinjoii of ffreat value in removing neruun eft'usianB, if given in full 
doHeii To a chilli of five or six years of ngfi I give ten gmins of th» io- 
<U(le three times a day, auj liave never seca ill cITcotH follow its oiuploy- 
ment. On tlie coiitrtini', Hn vnluo in ciLtiidnt; nbaorption and r«skiriu}; the 
natural stiite of the ineiubnuie has appeareLl to me to be verr decided. 

In endocarditis, also, blisterinc should be employed ; and if the tem- 
perature ban fiillen, iron and quinine ftliould bv ])n"tcribod, Tlie same 
tonic treatraent can be adoptetl in crwes of i^ericanlitiK aftor absoriJttou of 
the efftuion, for tho imtient ia usually I^ft Hjuenitc niid weak from the Bt- 
tAck, eepociJiUy if he have been treated 'vrith tli<! nnhi^ylate of soda. In all 
cases where the disease has bf^en coiikphcated nith endorarditin it is ad- 
▼iflab!(> bn Vi^ep t)ie child iu bed nn long ns jio^Kiblc ; nnd even when ho is al- 
lowed to get up it is wise to enforce the utinost attaiuaUo quiet. In these 
cases the hwirl is more likely to recover it«elf if its action be not excited ; 
uid, indeed, judicious rare during eon»-ale»cence may largely intlnence Uio 
fntare well-being of the iwticnt. Complete p<vat mod<*rat*a tlie hcm'fs ac- 
tion. ami oUoive time fur Iho hutiltliy rvuio^iil of infliLmuiutort' pruducbi fmm 
the valvea. If such producbi become urganiced, tliey contract the tiiwuefl 
Bad cause puckeriug of thi> valves, with all the evils nhich the reEiulting 
hindrance to the circulation must inevitably entail. 

If nui)]>nra1ion in the pericnrdiuin in suB|>ected, the aao should be care- 
fully imiicturmlivithft hypodermic syringHiu the fourth or fifth iutetwace, 
near the left edge of the i!tt«rtium, to ma^e nure that the fluid is punuent. 
If it prifve to be 80, the question of evacuating the contents of the peri- 
cardium must be considered. Professor Roiwnat^in haai-eported an interest- 
inif case, in a Iwy of ten years of age, in whom recovery toolc place after the 
Boc liAi.! been emptied. The penaLi\lium was opened by luci&ion in the 
fourth iqwce, near the stenium. nnd iifter the pus had escnpcd. two drain- 
Bge-tubcB were passed into Ihe w(«und. nnd antiseptic dressings were em- 
ployed. This form of pericarilitis is so fulid that the operation sliould ho 
dccideil upon if the slate ol tlie patient offer the slightest prospeet of ita 

Hoflcular rheumatism, whether it affeota the abdominal wall or the 
muactea of the neck, must be treatetl witli stimulating nppliciitions and 
witli warmth. A good mercurial jmi-ge to relieve the bnweis is useful. 

In coHeii of chronic joint painx affcfliiig children who are old sufferers 
from rfacumati^nt, it will he often necessary to change the conditionn under 
which the patient hiia been living. Removnl to a warm dry air will often 
do wondetH. Oreat nttentiou should be paid to the action of the skin and 
kidnevH. Fixe or sis gnvins of hicarbomitc of iwtasl!, with an equal quon- 
titjr Ol citrate of irou, given three times a day, will bo foujid of service. 
FermeDtAble matten and scid-makiug articles of diet Hhould be taken with 



AKoxnHT l^e Don-tiifectinns general iHsenMs inft>' be inolntled tlw curioun 
condition in wbirb Hppnrentljt- s^KtutJuiomis gnD{rr«n« beoom«« tlereloped 
in various parte of the Iwidy. The l«sion8 *rc often F^-mmptritiftl, but are 
not BO in e-rert- cnso. Somctimeit the lower limbs are the pitrta affecteJ ; 
but iKirtioHH of the fnce and trunk mav be hIm^ attaclced. Children, tbs 
imtijt^otH nf this leadcner, are not nlwitys (■nchectic or otJurmso «nfMbIod ; 
nltbou^h in muiy c&^cf the gon^rouous proocm occurs in conToleecents 
from iicutc or •.Icpi-vmiog: diwaBe. Aitci mvaalv* » eqiecial tluipomtian to 
guugrene is oc(.-iu>iiiiiiil)y diBooverod. The nauie tendvacy is dit^luvcd, hut 
less frequently, aft«r otiier acute epei-ifio dineaacd, as tioarlaliuft, variola, 
vnriocllN, (uiil «iiU-rin fever ; and iuHnuitark- conditious ^-uemllY, rouihiuL-d 
with poor (dckI, hftTO bccti cited ax iiredixjioKin^ i-kuhl'S of tlio gimgrvnous 
letiioiia. It is Kuid to hv looro cuiniuuii iu uuKI thiui iu wanu ueuther ; nnd 
Botue obeei-veni aie dieiioaed to look upon a low teoipemturd of the air an 
ooe of the causes of tbe miachief. 

Iu tbe caso where the diMnm ripiinan* iu a well uouri«b<'<l child who has 
Dot previooslr bocii fflibject to any enfeebling influence, the etiology of the 
lesion is obnnure. Raynaud, wbo was tbe first to desciittn a " syniraptriral 
gangi'one of tbe exireniities," attributes tlie affection to a spnsin of t}ie aiv 
terioli^s, followed by a niigration of blood-CDn)UHcleHau<l ti-aiiHiidfLtion into 
tbo Kkin. He utntes thut he htm ur-tJc^i.!, with tbe opbthalmDiwopo, Bpaein 
of tbe urtGriub'H of the fundus uccuU in tlicM cases. The disenao is somo- 
timeB assooiatvcl with iiitcnnitttiiit h»^maLuria; aud Dr. Gi<o baa reported 
tbe caao of a little pirl, aged tire yeai-s, iu whom ftaupier* of tbe vulra wiw 
combine<l with cmlnilittm of tb« kidney ntid tbe brain. Still, in nrnny comb 
DO le«iuu of tbe nst-eni or nrti-rial 8y»il4im i* diKeov^-mhle on the eloaest in- 
vestigation : ami no t'viileriec li«» yot hccn bKnii^lit forward pointing to 
any centric or nen-oua defect capable of excitius uiortifi cation of the ti»- 
HU<^.<«, altlioiiyb the Ryiiinietriral distribution nf the lenions ia BUcgfstive in 
mniiy cumos of sonio tiiich mode of origin. Dr. Ne(3npil, in €>\plaining the 
mdcbanisni by which Kpontnneonn gnngrene is jiroduced, assumes the ex- 
istence of u fimctionnJ nerTonn ilcra,n;,'t-nicnt. Tliia writer iiprccs with 
Riynaud in ascribiag tbe arrest of circiilatinu to » spiwra of the nTdls of 
the ftrteriolen in the part aftected. He supposes that owing to irritation of 
aenaory and centripetal ner^cs the reflex centre of th<> ^-aMOcouBtrictom 
wktch control the cin-uLiliou at the extreuiitiog of the hiubs iB excited. If 
th(! Hpauui be prolonged ajid be eullicietitly intense to close the arterial 
obaonelB, gaufpene of tbe part may bo iuducccL 

Children of all ageji may fluffer from tlio diacnse. It may occur imme- 
diately after birih, or may appear in biter childhood. It i« not always 
fatal ; but it tbe gnngr*ne'i» oxtenidvc atwl penetrates deeply tbrougb tbs 
skin, it Beldom terminates oth«rwi»e Ibau unlS'TOurably. 





Giuif^TBoe OH it nflTccts the mouth ami the hmg i« ilcacriboJ elHcwhon*. 
In tlip pretWDt chapter gangrene of the Hkin und UDdcrl^'ing tissues will 
atone lie cnnsitlered. 

Morbid J»i«/o'/iy.— Ganfrrenc tony affect the h€«ltlij attin or may attack 
a bliHlvntl KiirfiH'c. Iii thi; tlnit cafle tlic skin becomes darh blue in colour, 
■lul then idmott black. Itttcousisk'tifO varies. Sometiirio« it in bnnleiitKt 
feels dry like parchmtnt ; in otliera it is softer (ind moist. At the mar^ 
gins of the ffiuigreiious patch the skin ■» rerldeneil ajid inflamed. Innteiul 
of blnckeDSd patches the gangrene nmj wtRiime the form (i( iilirfrs limit^l 
in extent These uk-ew ai*p circular in »hnpo, with abrupt, pleaij-cut ed[»P9, 
and their depressed Roor ix formed of a gray ur bliwkiaU Klou^b. Th«v 
may penetrate completely through the hkin. 

flTien piuigrene attai-ks n hlisterpd Hurfnce the lesion is nmially more 
fiupertii.-iul tbnu in the fonnor cn»i:. It oppcavfi in the fonn of a Ijg'htish 
gniv hIoiikIi. rmirbled hen; tiiid thcri" ■with n Wult-t tint, 

SunietimeH tlie gangrene penetrates coinpleteljr lliroiigli the skiu and 
mbcuLaneouB lissnea. It mar then be found in two forms : a moist and a 
drv variety. lu tlie moint form the ^-aiigreuoua patch 19 black, softened, 
and infiltnitud with a dirty, reddiinh fluii3. ItH odour is esressively o(fennive. 
nod the tissues atTeeted Hp[iear to bo I'diripletely converted into a putras- 
eent pulp. Often it beginti as a §uiall piuiple, which changes into a bleb 
containing thin pundent matter. .Vh the pmcesH eontinnca, more and 
more skiu iKtitoiuon involved, aud a ei)usideral)]e extent of .■tiirfiine may bo 
rod, flftdematoutt, and l>f>t;f;y to the toiioh. The cyatre is iiturilly purple. 
On this Burfeioe bkWa farm and burst, leaving Hpt»t« of Kangrt^nc, The 
doughs unite, and if the patient .wirviTe may lieeorae limited. The gan- 
grnioun pirt is thai thrown ofT, leaving tlie luider munelea exposed. 

Whiju the gnngrene osBiimcs the dr>- funu ltd antttomical chnmcteri are 
■tmiLLr to tbom; of hl-uiIl' giuigrf^ue. SViL Rilliet luiil Btu-thez describe a 
ouie iu wliich the skin of one leg was completely iiiortiSud. On the toes 
it was sbrivelte 1 and blaeki^h. Elsewhere it was transparent, hanl, red- 
AitlUt and elastic like n piece of pnrcbuient. The dried nkin wr« ho trans- 
pHrent that the injected venoiiti radicles coidd be neen ramifying on the 
nnder surfkee, aucl it had a curious resembUiice to the rim) nf bn?on. 

Id some cases ante-mortem clota have been found in the nrteries lead- 
ing to the nffected part : hut in not a few caaett nn embolus in to be found 
io tint femoral or other art^irles of thfl di»tease<l limb. 

A common neat for thia flponlaneous gangrene is the vidra in the fe- 
male child. Hero the gaugrene usually bcgiua on the labia, and iniiy 
sprsHd thence to the interior of the viilvn^ to the anus and thesarnira. The 
a(Se«t«d porta are dry and hUicltish-hrvuvn, and may slougli otT. Icanng the 
mtuKles exposed. In iii:de inbmts the Hcrotum ih ttometimee att/ieked. 
Often the pntches of -^ngrene are not limited to one re^on or tu one 
limb, but oucur in sc:iLtereJ splits of various tiizes situated on the legs, 
the anna, the buttockft. or other pai-ta of tJie body. The lesions are then 
ofleo symmetrical, attacking corresponding parts of tlie surface on tlie two 

Sumploma, — ^Chihlren the snbjecta of this tendency to spontaneotw 
mortification are lialile to nttjv^ks of vhnt htw been railed " local anpliyxis." 
80ms part of the body — U-slhUIt a finger, a tot', or tlie whole of a hncd, & 
foot, nr OTOn a liiuli — hocntncx <:<xce»«ively jtainfttl, and i» natieed to be 
punile in colour. It fcols coltl to the touch. The tint may deepen to % 
anil lenden hue. After tliree (ir four hours, diuing which the greatest 
anxiety has been excited, the piiin subiddeR ; the colour of the part grows 





li'l^lifar imtl then bcrnmc-s nonDnl, and the nstural wtirmtli retonut to tiie 
B^Q. TbOM AttAoka Arc sotuetimes accompanied by Mrere abdomiiul 
[min. (X^cjuioQaUy, too. tber hr« TollondJ by li^iniiituriit uf a (liutiiictly 
intermittent cfaaraot«r, 1U«" water Iwiu^ uurmiil at Honit> timei^ r*<l n-itli 
lilnoil nt others. The attacks of lonU oapliysia do uot alwan sabside 
liiu-mletitJj'. In 8otu« cases the symptoms grow ftlowly none, uad tli« af- 
fected part becumeH giiu^r«tii>UK 

Otmgrvue ovriira Ui two priiii'ipa] forms: dMseiiiiuat«d fuul more or 
less Byiuiueti'ic&l guDgreiit, and gaugr«&6 limited to tlie extremities, tbe 
mlva, or tli« scroturo. 

Itt tho iii*m-mh>ale4 x'srioty t]i« disteiute begitin in Rcattrrat no(l;ilM or 
pAtcbea. The child for eomo dn\'» appcora to bo unitKiulJ^ dromj, and 
then, if oM etmuffh to speak, compLuuH of puiu in Boiott port of tlie body — 
the tbiglis, legs. buttncKs, or *nuH— and Urid jKitclieK ninke tlieir app«ar- 
uee, which grow i-Api^lly dnrkcr iu colour. The patches aro Itiircl nnd 
toutrh to the touch, and avum to b« tender, for prewure elicits iiigns of 
Buffering If the patt-ljcs iirti few luid small, the h«»«*1 health may bo 
littlu aflbcted ; hut if tliey itre large or numerous; lh«re miay be vomiting, 
lictidiiobf , and general mivlaiee 

Dr. Southcy hart reporttd the case of a little girl, two and half year« of 
nge, who hud a f«veri)«h attack accompanied by piiriwric epoU ou tLe 
limbs. Slie aoou recovered, but some months nftorwardH hod ft nocond at- 
tack which lusted three doTH. About a fortnight later the «hild complained 
of headache, and Raid hIir lia<l hurt bcr legs. The pnin wan iucroued by 
friction of tho limlnt. In nibbing (hem it was noticed tlutt tho akin on 
th* bockii of U)c colrRs was livid. Soon aft^rwaftla tlie cliild vorait«d, com- 
plained of headache, and wna fvYfriah. Towards thtr evening the pntchea 
wero Been to have estendoil up aiid down the wUTeB and to be darker in 
colour. A similar appearau<:e was noticed at the backs of the anus, and 
on the following moruiii;; tlie buttoL-k^ lind become Urtd. 

When mliuittud into tlie liospital ou the aecou*! day tlit' child wiui uiori* 
biuid. Tlte pulse at the wrii«t was feeble oud KOUicwlint uiry, hut could 
stUl be coun1««L The tibial pulse coiUd not he detected. TJie patches of 
IJTidity felt haril and tough. Tlie lunga and lieart iippeared to he quite 
healtliy. Biiindy and milk were given, and tn~n doaea of nitro-glyoerinE^ 
but oil witiv vnTiiit<>d. Int4>lligenco wax preserved until evening. Conml- 
Btotw then occurrt-d, tuid wcrehrctiuiintly ri'pmtvd until tho child's dealJi at 
11 jMi. The itluoss altogulhiT laHtcd ouly thirty-two buura A poM- 
moiiem esaiuination of Iba body discovere*! no coaive leaion of the viscera, 
nor could any embolus he detected in the femoral or other arleriea of tlM 
left lower liiub, whiuh was the ouly oue examined. 

3i£r. Aatley Bloxiuq Ium kindly commiinirnted to me the partiuuliirK of a 
caw of B|iontaueoiis gangroue which u-ao uudi>r his cnre in th« Charing 
Croas Huei>itaL The child — a little t;irl of ten mnutlis old^had been ail- 
ing for eight weeka. \ small pimple then appcai'ei:! on the re^on of Ilia 
iiinrior angle of tJie ttcapula. The next day a head formed on the pimple^ 
and become ItUcd with purulent fluid When the child waa admitted * 
day or two aftvrwards (on August ItHk) she wosiKOu to be pale and tlitn, 
luid was said to be wauling. The ubole of Ibe acapulnr regiou on tite right 
side was cedematoun, rv^\. bogg^, and boL Iu the centrD wiwi n purpuric 

Slob oil iuvh and n half tou/by th)f»e-<|turtera of au inch hnxKl, tho bur- 
rs of wliicli were quite pur{)lc. Ou palpntinu the patch gave a boggy 
SBBsatiou to tho fiugor, lut it bum fluid undenieiath tbe akin, llie tempecfr' 
tun on Uw fint tveuiog wt» 101. it , 

ePONTANEOrS GAKnilESB — tartttjes. 


On Augn»i Sfltli tbc patch had nURbU)- cnlnrfirpJ- TL-mperaturo : in the 
uoruU)^, 100.6^; iu tlm evening, 101,2". Pulse, U(l ; ivspiratioDB, 60. 

Od Aoguat 2lBt the pstcli woe much larger, meaffuriof; three and three- 
quarter iuobes lon^ h^ two am) one-LaJf inches broiuL Some buUiv Imd 
■iipnnind on tlie surface, RDd ono of tLexe bad buntt, k-nviii(j ii gniiill slough, 
niere was do teiiilerucei^ nt llie gaugrenoiui part ; iudei^ the oppoaits 
nppenred to be the cose, and tiie part aeemed to w iniuRiially iletoid trf sea- 
nUlit/. TenijNinLtiire : in the morning, 0A°: iu the evening. 1)9.6°. PuIm, 
190 ; resptnUKHiB, 00. An ammonin mmI l>ark mixture wiut ordered, uid in 
the evemnt; the part w&s veil ]>iuiitcd with utrong nitric ncid. The n{)])lifia- 
tioQ caasfxl no pain. Tbirtj dropt* of bnuidy were ordered every three 

Aftor tbi.1 the nlough did not ftirther inoi-cosc. On tlie MOtnur, it b»- 
KWi to Ke{)fimt<.\ uud the surruundiiigu-dcmu tu mibside. Tliciro 'vrEUi a little 
disrrhtBB. Ou AiiguBt 24th p&rt of the nlough came awav and exposed the 
masdes. The cbiid became very fretful and weak, ttnd died rather sud- 
denly on Augusb SVth. 

Vi^en the gangrene attacks the fsiremitiist. it mny be seen iu the finger* 
and toea, ur lanj spread to the hands and feet, or even hif^er up iii the 
limb. Children so affected are usually pale, onder-nouhshed, and cachectio 
in appaamnee. After a few days of morenrlesa initability, lonof appetite, 
headache, sleepinew, and geneml inalairte. th^ jvttieut begins to oomphiin 
of aerere painit in tho toe«, which may exten<i for «>me distAuee up the leci; 
At the same time the ends of the toes ore noticed to be diUI red or porple, 
and their senfiiliility is foii]i<l to h« blunted. The painn continue. There 
may Im> snmp (cTpr at night, and in thn morning tlie lividity of tlie ends of 
tbo toeH in seen to haw extended tu tlic cii-cumforcDic of Ihf uuii At tliui 
point the isyniptotuti may tnibsidp. the paiiiH becoming mudcrntv, tunl tho 
lividity fading and diHappearing ; or, on the contmrj. tlie diaeime jnay go 
on to complete nphacelu.'i, and extend to the whole of the foot or even of 
the iimlx Thu8. Fran^'oU nx-onU tlic case of a cliild, three yearn of age, 
in whom the gaogrena involved the whole of the foot and lower part uf Uie 

This form of gangrene may be dry or moist If the former, it OBOumeB 
the character)) of senile gangrene, becoming tiei>amted by a line of demaiv 
catioD, and suliaeipicntly detoehod. Itaymutd ri'iiorti; the cnse of a Little 
girl, aged eight y«Are. of good couHtitutiou wid iit^altby appeanuiee, who 
beft%n to comnhun of Beven; mins in tba feet and lower halves of the legs. 
At Ibe same time the ends of the toes* were noticed to be blue. The pains 
isenMwed and the child iaiih a litlle feTcrJidi. Tbn fourth toe on ejtch foot 
became alatc-coluurud. nnd tJio other toes nhowcd Hpots uf livid ri-d. Tho 
mortified partii weru in^wnsiblc to the toudi. but ttic pains continued and 
were worse at night Tlie apjjetite reiunined go<Kl, and there whs no diar^ 
rbuso. Aiter a few days the pAinu ceiiseil, aud the gaagrcuoun patches 1^- 
came limited by a wcll-definGd hue. Iu about a fortnight the toes dostpiiv- 
mated. Dry bruivn wabH bectuiie detached, and left the skiu beneath them 
tialed of a pale violet colour. On the fourth toe of the right foot, the one 
which had exliibite*! the lurgest patch of gaugriiue. a blnclt. crust was tlirowa 
ott, and a auppumting surfacu wan left wliich quickly lieidoi.]. 

Avery siiuihir caBe has been publJHLed by I>r. Soulhey. In thin the 
apota of gangrene were accompanied by HuJirutiuieouii mottliugK of the 
trunk and limbs. Thew inottlings developed into a mi«ed nwh like cry- 
tbema tubereidatuni. The emntioii at first iti^-hod, then bn'soie tender 
Hid painful, but ovvntuaUy subuded, leaving merely a discolouration of the 



(tkin. It«cor(inr in mioli cAsos ih someliinos followed YtT nn nitorl: of p&r , 
ox\ ttiiutl ha-muturift, in 'n-bicb hage quAotitics of crnrtola of (UcoUte of uiao 
are paKsed witli the urine. 

lu tlio moist gnngrene of Mie extremities the nfyrateil pai't — which ti 
cocamooly the Aiul of n linger or to<- — i»RwoUffD, nnd thcc'iiidcmti^iitnuwdi 
up by red Borous cffuiiion. As the lUtitructioii of tJic liiisur« of the pari i 
proceeds, the articrulatiuD may be Ui<] opuu. Sunietiines moist gnn^^rpne 
of the oxtr^mities is combiDed nitb diHseminatecl B]>otii of n kind siioiltf ' 
to Uiosc prvviuuaiy JciKnbed. Tbu», 3tUI. IlilUut lUiJ Biirth«x refer to the 
case of a little girl, a^^ fuiu* vi-ant. who vrox uudvr tbt* caro of Ix^gciidro. 
In this child moist gangrene Rttacted the ungual phalanges of Ihe riyhl 
thuuib null luiddJo fiuger — iu the liitter laving o\ion the second uticuLlatioa , 
— and the unguul phnlaux of the left forefin;;er. Moreover, gnngmioua 
blebfl filled nitU bloudy serum foruieil at the lKu.-k of the xhoidder, in the 
low«r pJirt of the dcrsnl region, and in other parts of the body. At last a 
double puoiiiuoiiiik (U-t-larcil ilnelf, and the ohild died on the tiiiith day 
from Ihi- bc^^iiinii)^ of the illiiexx. 

WixtfD the f^ugrenuus procesi! attacks tb« vulva, the K-eion 18 usually 
seen lu a cacliectic or veakly child, who bs& lately pita»ed through an ex- 
hausting illueaa Severe oieasles oiccnrring in n ac^-ofuIouB subjert is t>om&< 
tLia«8 followed by this dangerous sequclit. As in f^angrcne of other part* ij 
the eariiest Kytuptonu ore usually losn of appetite, headache, asd uausea^ 
Then the child coraplaina of severe burning pains in tlio genitshi : and a 
light red cirRumschlied i)atrli ik seen on une of the labia, often on itx inter- 
nal aspect. Around it the titisuesaro dense and swollen for some distance. 
'thv, patidiit vriva fretiuuntly witli tiie jwiii, uud tteciiia to Kufl'or f^'-at di^ 
treHg ill poHsiitg lier water. After a diiy ur two iwhy gray sputn appear. 
These ai-B circumBcribod and limited by a light red ring. Soon their 
colour changes to a dark brunn or black, and the tj:aiigreue t^weads to the 
upper port of the vulrti. the pfrLueum. uud the anus. Often there is ft 
pundeiit, olT(>uiiive disoharge from the diaeiuied snifinoe. The g(>ueia] nyiuD- 
toms also become more pronounced. The pnlae is small and rapid ; toe 
features are pinched, and the fare is very pole. The child lies moaning in 
her bed, and co!nplfuii>« of pains not only in the diseased puts, but alio in 
tlie Iimb<^ and bo<ly. Snmetimes a wat^-r^- diarrhoea eomw on, and in that ' 
CUMu the child soon dies cxhauirted. If by energetic treatment the gan-! 
grcuoiis process can l>e arrested liefore it is too late, the slaughs Beparate^ 
tiie Hwellitig aud darkneaa subsido, and a gtunulating surhtee is left wliicb 
quickly hcnls. 

The giUi^n^uouB patch is HometimeB stuglc and of limited extent. Often 
the caKe is finit seen when the separation hati partially oecurred. and a 
(doughy -IfMilring ulcer is found on one of the labis. Still, hon-ever ttmall 
the loi-al lesioij may be, llie geucntl Bymptomei are severe, and on tu-count 
of the exhniistod utftte uf the putieut the dau^'er is very greaL At the 1>^ 
ginning of the disease a slight (ebrile movement is sometimes notit-ed, aud 
the tcniperatme may reacli 100"^ or 101"; but tlie pyrexia iii<uully tjuicUy 
Hubsides. and tlw temperature for the romaiuder of the illness is below 
tlie level of health. Death in caues of gnngreue may oecur fi-om pxliaua- { 
tion. Honietimc'^i it is ushered in by a acri«s of couviilsive attacks. In Dr. 
Gee's cose of gangrenous ulcer of the indva an extensive emboltsmwae 
found in the cerebral arterieH. 

Oiagn/mi. — Tho dingnoxis of BiKvntaneous gangrene in the child pre- 
sents little difficulty. Tlie only cow iu which a mistake if likdy to bo 
miKlc is that in which the diseasB attadis the estreuiities of the llugcni or 


In tint cMe (lit^ prirkin^ pain, coin1>inec1 nith the livid line of tbe 
u imggeNtive of chilblains ; nml, iij{l<>»il, ncc^ntxlin^ to Ru^i'Daud, 
<!aaE» of this variety of giui^^tin hnvn ht-ttn oUtin confoimd«<il nt the* begin- 
iiiD{{ witit tliis coinmou uit<l uim^tScatit <liBaa8& In most caaes of g&n- 
greoe. however, the pnius are Car more serere, tho oocurrence of tlie loeol 
s^ptonu id more ubnipt, iind sevemi lingent and tocR nre itttaeked siinul- 
tuuKKialy. 3Ioi-eov«r, the gftiigrcuous ii^oa ii> often found at a aeaaoD 
wlieu tbu couunuii cliilblHiD i^ iiut usuiillj miBereil from. 

/VwjFfttBtii. — lu everv c^no of Raugrnni?, wliutever poi-t of the surface be 
attae1ted.theprogiiotns lit tiiost unfavourable. The piUieDt.mdc«d, dOMBOt 
nlvn^rs ilie, but inHtanc«a of recoven- nre rare. If tlie pntictit lie a new- 
born iuffiiil. or ft cliild of wi-nkly foiwt.i1 ill ioiij be iiiiijk' be considered to 
have Hlill fewer »hiiii(;98 of piHuiii;^ uitfelv through ho formidable mi illness. 
The most faroomble eases toe tluiae in n-hicli Uie ;.'aii(;p:<^iit:! is of the dry 
rarietj and remains limited to n finger or toe. If tbc gHrtgreiioiiH pi-ut^wtis 
uppeara «uccemlv«>lj' in several parts of tbo IxkIj', little bop« of rouuvery 
can be eotertaiaod. 

TVealmerU. — lu all ciukb where n cacbectin child in iitt/ickcd with gan- 
grene, every eflbrt should be made to xupport the strength of the piitient, 
and improve the Rtate of bin nutritioi]. He tdiould be tiupplied nith as 
much Dourinhing fooit un he von di^Cftt. Muiit — pouiidfil if iibcensar}', uud 
Ktruiut^d through a fico tdtive — eggs, milk, well cooked Tcgotnbks. and a 
judicioua (quantity of fariuatwoua mutter muat form his diet. Stimulants 
ar« always required, iiud the ohU>l mny take lialf an ounce of port wine, or 
tb» SL Knphuel tntinin wiue, diluted with iin equal proportion of wat«r, 
after each quautitj' of fuoil. 

If the patient be nn infant at tli^ hrcrut, we should inquire if the sup- 

' ply of milk in ailei)uat« to hia uecetuities, If the breast milk i^ poor and 

ixwulHcient, additional food nitint }>p given hh directed elsewhere (see page 

003). White wiue whoy in very nuitablt^ in thei^e (>a9&s. Toniea ai-e always 

TWinireil Quiaiue can bo givtua in fuU doaee (two gi-uinR for a child of 

years old, three timea a dny), or the nuimotun and bark mixture can 

lOldered. yir, Oipps Rpenka highly of opium given frequently in Hmall 

a OUKS of dtaneminateil motHt gangrene the heat of the pnH should bo 

"lliaidtftined by hot ftpplicatioiij*; ami dirccilv « slough is notictd on the 

surface ita further (i>;tonniini «liniitil Iw ptwentrd by the frei? imjilication of 

,s powerful esehiu-otic, Strong nitric itcid should bo appheit once thor- 

jhiy, and tlie |>art iniiat be then kc]>t covered nith hot poultices. Wlien 

f'llie slough wpartitf'K. tho requiting sot's or tsoron can be dresned with a 

' CMrbolio-aciil lotiou five drop^t to the ounop of ■wnt^'r), nr n solution of bo- 

ncic acid (twentr gi-MinH to the ounce). In nil cjLm.'8 of gangrene of the 

toIth tluH methoi^ nf treatment is UHeful : imd the local meanures employed 

in Uid trcfltment of gangrenous Htonmtitiq are equally serviceable when 

the Tulva is tho part affected. I'anot tuh-ocatcs the use of powder of 

iodoform, eHpeciaUy in cases of giuigrcne of tlic vulva. The ulcers muat 

b* first carefully cleaned. Then they must be completely filled with the 

powder, no paii of the raw surface being left uncovered. If tho uWr is 

TOj moist, it ought to be dresned twice a day. This metfatMl of treatment 

iia p«inle8% and is said to arrest tlie progress of tlie ulcer iu three ur four 

dAya At tho same time tlie surrounding (tdema rnpidW diminiahea 

When the gaogrcne is Umited to the extremities, the affected part 
etlluM be wrapped in cotton wool, and gentle frictiooH with a piece of 
j|*ww*l moistenctl with eou-de-Cologne are recommended by Buyuuud. This 


author diBapproves of the use of energetic local stimalants, and state! 
that he has seen very diBastrous results follow quickly apon undue local 
irritation. Directly a line of demarcation forme, hot dry a^Ucations, 
such as bags of heated bran or sand, should be kept applied to the seat of 
the lesioD, so as to preserve the dryness of the tiasues and hasten the 
separation of the sphacelated part Li extensive gangrene amputation has 
been sometimes performed, but without saving the life of the patient. In- 
deed MM. RiUiet and Barthez are of opinion that the removal of the dis- 
eased member only hastens the fatal tenniuatioQ. 

The flcrofaloua diathemH is on« o/ the most common of tte morbitl types 
of rroDKtitutioii whiRti we me»et witli iu the child. It U (uuQ'l in till ranks 
of life, tuid in tklmonl nil parts of the TvorlJ. It i&, however, espvcitjly fi«- 
quent id the t«mpi-mU' ):one«. being far less conimoD in very coin] or in 
tropical climal*>s. ThiB vice of vouutitution is oftou herEKlitiuT, and is 
then liaDd«d down vriih BinsvUsa pereist«nco from generation to genera- 
tiou. Sonietitneft. indeed, it is neeii to jmiss oyer ceriain memlwra of a 
famd^', l)ut (tvcu those vlio eucajw may not trsusmit complete immunity to 
their oQfnnnff. 

A cbifd who hoa the miefortuna to be lx>m with thiH unliojipy predin- 
positicu is li&hlrt to very wiileajireail eVidenceH of tlie conKtitntioniil fault 
with which h« is bunleueiL Hi.4 Kkiu, tits iiiucnuH membniiici). hia l)one8, 
}oint«, oriransof spcciid m.-usc. 1ud^'» iind lyiuphatio uyHUiu uro nU usccp- 
tjon-illy sensitive to the ordinurj- cnnsts vt disturbnucL*. uuJ may lUl or any 
of ihem become the sent of obiitinate deraufjemeut or even of inearable dis- 
in~1 Tbeiio mnnifoatatioiiH of the conHtitutionnl tendency lUtuaUy Uke 
Dlace curly. HO thnl scmfuEii ia uapeciidlv a dLcKiHtH: of c-liildJtood. Infaulit. 
mdMd. are in ^^»t meiisiire exempt from itit uttaf-'kti ; but after the third 
jear it begiuH to be common, and from tliat age until tlie fourteenth or fif- 
teenth year tlie iliatbems is most active. At puberty ttit auergy sensibly 
absLes, and xtrumouH diaorden are 1«88 and less fre(|ueutly met witb as the 
individual udranoM towuils middle life. 

Cbti^toii.— One of the most important of tlie causee of scrofula in he- 
reditary influenre. When tiie pareiita are actiudly suffering from the ca- 
cbexia, or Iinve KiifTered from it, tlis diilil is hardly likely to eacipe n share 
in tbe constitutional predispomtiou ; but when no such iuuiiifo»tation of 
Uu tendency bae been m.-en in the father or mother, there in a hu]K- lliAt 
bycarcfo]manaKementan<l attention in the kwHotheidtbthetiarae freedom 
may be extended to their ol^pring. But I><>iiiiie9 nctinU MTofiikiUK diseuse, 
crtLer (lebUilAting influfuix-tt in the puii^utH uiay dcturminc tlie strumous 
cxmsiikutiou iu Iheir children. Thus, the cancuruuti and tuberculai- co* 



chenn mil do tkin. Syphilis in th« third ffMiWfttion is ftpt to mocifesl'^ 
itself by HcrofuluuH diaunlcnf ; and ofiv in Uie foUier. or imperfect nutri-i 
tioD ill the mother during her ^leriwl of geatslioD, are aisn htdd to b« deU'r.j 
iiiiHtng causes of a congeuital teudeuc}' to stniiuuust oouiplninls. \\1i«Ui<ir ' 
merc^ iiviiructis of rflutiuiiatiip ou LLo piirt ot tJjo jiomittt nill cxerose Uiej 
same uifluciico is a (xucntiuu which has hucu ofton debated, and maiiji 
wi-iters hold tluit it oui do bu I du uut think, liowerer, there is nuy iati»>| 
[lu-tory proof that such & result ofta follow in cases whcro tliera in not 
already ii tendency tu llcro^lla in the tiuuily. 

Seiiidtm btiiug hei-iMlitur^', tb« diatlieKii*, it in cotuiiiouly held, may 
aoc|uired under conditions favoiirnblf to its dovclopment. It is true tliati 
frequently see patients who exhibit nil the signs of h scrofulous lesion] 
without any disroTt^rnble family history of scrofiilnus disease ; Init it is ofton4 
diflicult to tnu>fl out ht^'rmli tniy t-uiits, 0H}iccinlty when iho transmitted t«&-j 
dency luut boeu mild iu ita □lUuifcslatiutiN or has skipped over oae or two' 
ceue nil ions. It is more probable Uiat iii imch raees latent scrofula is 
developed by itebilitatiu)^ iiiHuenees iu eliildren, who, under more fnvoura- 
blc cirRuiuatanees, would bavft oitcaped nllof^ther. 

Tbo tMiuBi-s which ai-L- thus cnpiiblu of dcrclopiog^ the cAcbexia in ohU- 
dreu wlioiu> cuaHtjtutiuiiHl teiideucy in comparalirdy feeble, are all thflj 
Tarious agents which impair the nutrition of the body by weakening diges- 1 
Hon, checkiug aiiaiuiiUitiou, aud iuterferiiig witli th« tticape of watite mab* 
tum from tlto systuiu. R«peateil expoBure tu coM and damp ; an habit- 
ual ruai'se aud iutligestible diet ; abueuoe of frt-sh air. and confinement to 
clo«6, ill-Teutilated rooms ; depriratiou of sunlight and want of exerciM. 
— the continued operation of UifSf caii^'S. if il cuiiuot H«t up the diaeMarj 
ivliero no pr(*di>ii>oiutinu exists, has at any rat« a powerful iullii(<u«« in 
<-x<>iliiig the eochexia in children who luive Iwen bora the subjects of the 
dialhe.iia Even grown up persons expoHcd to miirh unhealthy nmditic 
are often fnumi to become wrofulous. Therefore ntuses whi^'h are cfipA* 
bk of renwaketiing the cachcxin in the athdt, aftej* tlie ag« inoMt prrtne to 
it bait pasiod by. mubi: act with still Ercntcr euerfjj- iu tho child. Certain 
fcYers liave the power of detelopiug or re-iui*tatiiiK tlie iliscnso in suita- 
ble HUbjecta. ^Slenslea aud whoo[>iug-cough have a wonderful influence iu 
t^is i-ospect. Uuiuodilicd auiall-|>o£ used frequently to be followed by oli- 
stiiiate sci'ofulous diiKtnlGni ; uud scarlatina con eount the sumo complaints 
umongtit its iu>(juelii>. "Where the prediH]KJ!>ition is strong, it is probable 
that any disease of a lowering tendency may auffioe to develop it, 

.Scrofiiln. like other cumplaiiits. liaa been aaid to ha^-e been ounimuuicutctl 
by v»cciu[iliou ; but that the disi-ais^ pOHMCwtBs any ojiecific morbid mutter 
nliich is capiible of ln;'ing conveyed fnmi one child to auulher by inocula- 
tiou ia a doctrine which has now been proved to be destitute of any fouti- 

i}forbld AnnfonTj.—Tlm stnii'tHml Ip«ions iuduosd by tbo eei-ofulous 
diatiioouj conniat in various chronic iaflummatioM with their consequences. 
Tlie«B hare nothing Rpecial in tlieir anatomical pharartei's to distinffiiuth 
ihem from the same lesionii occurring in non-scrofulous ohildren. They 
need not, therefore, be further rcferrt^d to in this piae«. 

Tho affection of tbo lymphatic piands, whic'h is so cbaroptcristiR a part of 
the disease, differs from the oidiuarr li*-[»cq)laaia indueed in a healthy child 
by neighbouring inflammatian in the fact that the swelling does not subside 
when the irritant which lias given rise to it has pfteee*i away, but contiaoes' 
ae a chronic condition. In the case of a healthy child the gland becomes 
more mscular. aud swells up by an iucreuse iu its cotpusoular eleniente. 


Th^e* mpiilly iooreaae, raultipiv, and enlarge, iiiul ucquiru many nudei 
wliich fiU tJieir interior, niia in tlic tii-st step^ In tlie secouci, one of two 
tbingn may tAke place. If thn irritAtioti HuluddcH nail eeU-prtnluctiuu in 
checkrii btf iw* ihe imtritioii ol tlic (iiand is interfen>d with, a fattvdegen- 
oimtioa t«kcs pliico iu tlic new ccUb whicli reiliir^^ tiit'in to a milky fluid. 
They are then Rl)Borl>wl and the gknd rpHumei* itN f<>niier niw. It, on the 
rantrary, the irritatioji pf-rsiat, the proiiffrnlioii of (n^IIh rmitiiiiifts; thry 
crowd together, destroying' tiie reticulum nad the cyipillnry network of the 
Chuid. lUTCst uutrilioii tiy their pi'Crwuiv, aiid IroiI l» nipid diniiiti'^nntiou 
and Huppunitiuii. Thix, thuii. wt an iictivi^ prupom cuudiit'Csl rniiidly. Id 
the Bcromlous <^hild the coiiree is much more protrftoted. The j,'laiid8 are 
ftpt to tAke on a chronic inflmuiuHlory prxiReHx. They iucrenAe fllowly in 
nze. and remain a Innfr time aa indolent IniiipA, appiinniUy lncnp»hl« of fur- 
thorcbaoge ; or, if t)ie nwDlhii^ have been originally aeute, no dimintiUoD 
in size takes place whru the iufliimiuatOTy procena is at au cud. In cither 
case the gland is filled wiUi proUferatiog rclls, which hv their pressure 
hinder nutrition, and induce an imperftx^t fatty (Ipgenemtinn, so thot the 
gland in convert«d either wholfy or in part into a ma*<a of pheestv matter. 

(Hands HO anVjvtvd liuvo a 8;>od<^ feci, uidcsn Llicre is niticli h>'pertrop1iy 
of the counectiTB tixMue, in which caa» ther bEK-oioe hard. Tiicir iiecitou 
ia pale red, passing into a dirty white or yeUowiah colour. After a time the 
whole glftuu becoiucs thick, tough, anfcmic-lookiDg, and ilry, and is then 
quickly converted into »n opat^ue, vellow. cn^eous luiua. Dixeatia iu the 
gtaudo is uuetjuidly diHtnbut«(L some ore mialteri^d, and even of those 
affected there is great variety iu the degree to ^vhich tlie pruc-ens extends, 
for some remain small while othera enlnri-e iiiiisiderahly. After rcmaiuing 
for a long lime inactive ono of two ehangos may ta1io plnco. £ithor tho 
gland snft«ii», nets up inflammution around, and evnciintea its eoiitents ; 
or the lluitl part of the ginnd ib absorbed, and tlio glaml dnindlca into a 
flbrouH inaw), or is hardpiied by the deposition of earlhy wiUh. The cerri- 
cnl gUnd.t often Rup|>urnt4> -, tlie bronohtal glanda ncensionally do ao, but in 
the Die^c^nturiv ghiude mucL u termination in verj* rare. 

Softening aud snpjiurution couHlitut*.' u cliief diuiger of caMcousi glundt. 

the gUnda of the neek thiti in of leati loomeut than in thoae of the cloattd 

' lOa, for their contents are discharged exteroally, and ore thus removed 
_.„ the body, Evon iu these cafles Mcondnrr couaequencea may enaue- 
Thi «xiBt«Doe of a chrouir tlischiu-^in^ itoi-e, aut-h aa often results uoni tlie 
aappoi'ation of the»e ghuidtt, is very apt to induce amyloid degeuf^mtion 
of ue Uver, kidney, and Hplccn. 'rhercfore these orgaca are frequently 
rHtfiMird in i-rrfiilTin "hii'lr'n lleaidea, there ia always dan^jpr that anflen- 
ing obofiay matter may give risie to an explnnion of acute tuherculojitH ; and 
many )«^r<ifidoii8 children fall victims to this fatal disorder. Li the ooaeof 
the broiuliinl and meMcntiL-ric glaiida softening and suppuration are atill 
more seriouH. on account of the etrect ujion neighbouring organs. Thin 
mibject will be referred to afterwania. 

Si/mj/f'/mn, — In a vri-ll-miirkud VAumplc of the Hcrofulous diathesJa the 
conHltt titionol tendency often exprevHcH itself in an muuistnkable niiuiiier 
in the build aud geiientl fl]>pearance of the child. He is stout and heavy. 
and looks as a rule older loan his age. The euI>ci)tancoua fat is usually 
orerMlcTeloped. and in places remarkably ea His face is 1>ro:id Jtiid fat, 
with a thick u]T])er lip, and a wide uo«e. The limbs wre stout, with Ihick 
ends to the bones, and the abdrtmen is incUned to be large. But altliougb 
tlie adinoae tiatnia is restively increased, tliere is a want of firmness about 
the child's fledi, and his Umbs feel soft and flabby. Such cluldren are not 



DeoeaBBrilj* iU-fnv«nir«d. Th« gcnornl mint of ildii-ncT imd rofiiu-uieut in 
the feeturen ie often rfid^emed hj tlio liu>;« bUc (ldiI tlreainy expreeaioii of 
the eye. by the high colour in the cbeekii, aiid by the rednewt and fulueaa 
of ihe li|>H. 

Soch climrftctcrifrtic* Kv, howorw, goftn only in pronounwvl cnacs of tli« 
diAthesia, Fuid even then are not lUiva^-atu bo fourid. All the tcodenciea of 
the (MTofulouB coiiHtitution niRy he active m a child withotit hi» prenenting 
nny mioh peciUiaritir-a of face or fiffure. Imieed, in many strumoim caiw* 
tbo child 18 iweii to have a spore &auie, with tWlicate featuron and a thin 
tajwuiircnt akiu — a type wbidl coiitonos more to the tuberciikr vnrifty of 
ooBfltitutiott tu 1>9 itftcrwatds deBCO^bed. But whether hi- b« atout and 
coarsely built, or tliin &rd delicately fnuued, there is one indication of tlM 
ilintlivtiu state which is sddom absent in a HtniDtoiisH)il>j<-t-t Tliin is tho 
nti<^iilnr activity of nil thoepitltelinl Ktructiires. The hair is soft, Uiiclt.and 
Itimi-mnt: tlie eyelashes and eyrV>roiv« tire well inark«<1 ; nnd in many 
rasen there is a rem&i-loible derelopmcnt of fine down covering the eni-a* 
clieeliH, sbnulilem, and Rpine. The skin, moreover, i» apt In 1* rough 
anrl wnlv, and tho nails ^^'i-ow fast. TliiB peeiiliftiiiy ninrks one of thit #»• 
fteutial fvntuv<it of the »cri>ftilo»e <linthc»i». vi:^ : a U-mleucy to rapid pro- 
lifuratiou of tdl tlic i-pithcliol and cfllulor L-k-niL-utti of the body. 

It has been said tliat tlie scrofulous diaUiesis is not tu itself il disehite. 
It is a tendency to disease — n tcmleney to deruijt^^uenls of stmetare or of 
function which liuds exprestiioii luider Huitul>le (rouditiouti in a variety of 
lesions. All these beur a common character, iiud vary in grnvitv socording 
to the tissue or or^n nfTerted. The lesious are intliimmatory in their na- 
ture, ftiid arw ch^racU-riaeil by rapid <eIl-i|:i-owth and rapid tlecay of tho 
newly fomieil eU^iiieuts. llK-y are not diKtingnishod by any hi««-ui1 aiift* 
tumical cluuiictei'S which stjuup Iherii nt oiiee njt of si'iiifulotis cui^^i. lu 
appetu'ance they do not (liffer from siuiiUrdcrftn):;«meut« occurrioc iu chil- 
dren of a healtliy liabit of l>ody. Tlielr coostitutional origin ia uiown by 
tlieir tedious coil nje, (or if n<tt stopped at once they soon pass into a chronio 
sttkte ; by Ihctr ttlM;7f:fiah reftjionjut to treatment ; and by their proncnoM to 
rclnpiie wh'cn appiirt^utly curitd. The disl.urbsncc origiuatcti under the in* 
3ueuce of some tridinf! and temponirily exciting cause ; mid tlie length of its 
eoTirae is often dependent upon the hygienic couditiuus surrounding tlie 
chiUl At tlie time of the attacL If these are astisfoctory, Uie derangement 
may be quickly recorered from, although it rcailily reeure when a similar 
cauae a again in operation. If they are nnsatisfactor>', as is usually thn 
CAM amongst the poor, the deiaoffement becomes a chronic dieorder, ftod 
increases in sc^'crity and obstinoc)' as tho days go by. 

The parts which are pmne to suffer in this diathesis are : the mucous 
membnmes, the skin, the l>niieB and joiiilH, the organs of wecial eense, 
and nboTc all the lymphatic glnuda. In vluttever tiflnia Uie leskm is 
aeatod, the nvighliouriiig lymphatic ghuids uro liable to sufier ; and thU is 
a fact so generidly recogiiiEcd thai Hmongst the jmblic the term *' scrofula " 
is understood to mean simply a chronio enlar^meut, with tandcoey to 
BUppuration. of the glanda 

The niucoiis membranes in all strumous children are especially aenntive 
and subject to catarrh. fioBtric nnd inteflttual catarrhs ai-o rery oommon ; 
and we find besideE, coryza, nphthalmia, catarrhs of the throat, eu-, uilI 
air-puMkgee, and in girls of the ruLvo. Alt these, beginning as caturlia, 
pass quickly into ehntnic inllammations very dilhoult of cure. 

The afl»cIio»s of tho gaMritt and intestinal mueoiis niembniBee will be 
conaidieTed in another place. They do not differ hrom the same derange* 


BMnla B0 tbej occur in healttiy sutjei.'ta except ioi Ui« fact — iukI it in « rcry 
impoitaot on«>— that in s>-mfiLloii» cliil<Irei) aueh catairlui lire alwuiTM acxxiin- 
panied by fpver. Tbis is eeldom Ibe cftw nitli lioaltliy chiltlreD. If 
prrexia be present with a simple gnetric catarrb, it affords & stiung pr&- 
«mi|>tinn tliat tlie patif^iit is of a scrofuloiie contititiitioo. CnlairtiH of tbe 
tDtetttino ill tlieee ctuldreo often set up ulceration of tlie mucous luftu* 
bnse. Tliis ia nn obstukftta iMion and moy load to sdrious oonsequenceB 
(•ee Ulcentioii of llie Bowolfi). 

Cat*rrl)B of the iianal pasH&geH leading to onvmi, and ovon deiitnictioD 
of boD0, m.iy Iw HOTin. Ohntiiiate cUscIuli^a fmni tlia noHc in % bnbj in 
generally of sypliilitic origin ; in n chiUl of two nuJ a liaU years anil up- 
ward it is murJi nmrs cumntDnly due to the tirrufuloun cachexia. II ia 
TDfy obatinatc, girea rise to a distraBsdng and perhaps unavoidable habit 
of anuffliag, impai-ts a uoeal cbarticter to the voice, aud Icn^ls to crncluuf; 
and excoriation of the upper lip. 

The eyelids and eyeii may bu alTect^iil n'ith tinea tar^i, piitttular ophlhal- 
djia, and keratitis, with intern* lachrj-mation and photophobia. 

Phar}'ug«al catarrh is a very coouiioa affection. It ia aUo a vrry iiii- 
jtortAUt oue. for it i« acrompauiad by some enloi^mont of the tonttiK and 
eoDsidenible swelliii^ mid IliJclfoiiiug of the posterior Dureti and ljiu.*k of 
the [luices. C«u»eqaeQtly there iu ocdusion of the Eustachian tubes and 
dt-iufnt^sa. On inspficting tlie liack of the fFiurt^H in nnch c-iaea vif- find tlie 
IDUC4MM meuibrane of adenp red nolonr. It in Hwollfn and iitlvttly, and ia 
eorered witti a thick mueo-piirulniit worction. Th*i cIohum* of tho Eusta- 
chian t«I>fi is not due to enliirKenifnt of the tonsila. but to the aviclUnff of 
the mucous membrane. Children ^n iitfprted present a ]>eculi«r apppar- 
msin*s. Tlioy have a vamint Ionic, lioid tlieir mouths half o]Jt>ii, ajid, heating 
bat iuiperft.'clly what is xiud to tLcio, huaitalo and aru coufiiHcd when 
•poken to. They an- not rvnjly wautiuf^ in intelligonci:. but uu iicruuut of 
iftsir dea&eoH appear to be so. On examination of tbe ear the t}iu[niiiuni 
i* Men to be dravm in, but it retains its tranalucency, aad there ia no 

Otorrhtea is vety often met with in serufiilouii (.ThildifU from catarrhal 
inflammation of the meatus. Tbe inflammation tuav spread to the inner 
ear, in which caae perforation of tlie membrane always laliea plnoe. Severe 
primary otitis may also occiu* as a result of cold or injury, or as a sequence 
of acarlotiDa, m«n8l«s, and smnll-iios. 

Pulmonary catarrhs in strumous subjects may become chronic and give 
riae to winter cough, with emphysema of the lunga and persistent hj-per- 
accr o tion ; or tbp eatarrh may spread to the nir-iroUs, inducing cbronlo 
flttirrhal pneumonia nith otl its possible consefjuonees. 

Various akin affections occur in mibjecta of tliis dintliesia, nnd are gen- 
trsQy the earlieet manifestation of tbe const itutiona! lendemy. Acuta 
Qceemaa are common, and aUt^'ht dcjirr-KHiug rauiu^ may give vi«f> to an 
oUbrcuk of impeti^DOuri or vcthymatoua puatulea. I.iittlu scratchctt aro 
^ to run into festerinf; sores which may i>e slow to licaL Occaaiouolly 
*e find rupia. pemphigus, or lupus, but these are rare in childhood. A 
kot unoouunon fomt of alT'H'lion of tbe skin is seen in babies and children 
tnder two years of ag«. Tliia be^^Qs as a small lump— hard, pninleaa, niul 
ot the 8iz» of a pea or a smaJI nut It is seateil in the subcutaneous tisNue, 
■&<1 the stdu over it is at ttrst freely movable and is uatuml in colour. 
Qradaally nn wlheaion forma between the little maas and the integument. 
Thn akin gt-ts red, and after a>Ii- time t^'b'PH way. and the cheeqr 
contoDtu of t)M nbscMs aro evacuut^jd whul! \ or in jiai-L After disdiargiag 



bt Ml 




>«f IW 






lil tmi^lo. 



■^T. l^ its Mat 





I IMiMl. 
■a, (imni 

ha^an t ^ nv m l toare^oafiv iBiiMit fapai the aeaJt of Um 

fba atiasaBd axi> m aflbetod. tbc pais ■ tt 4e f T wl to tfaa 

la 0Me«Mo(lb«lo«8rMmMl T»telne,it u felt in tin 

Ibe artam, or crm io tbe iqipn fart of liw fara—thoQe 

^ Um tmriM noeupjr tim (Innsl ipiiie, the Gnh- itiicomfart twnpkhwd of 

IMjr ba In 111* miIm of Um Umwkz, the niddle Jme of the chest in fnat. or 

tlM *fiicmtt ti t m u Is iliiwiw of Uw hualmr Teiietna Ihe paia is mAeeted 

ir> t)j* j^'lvii. r^ to Uw lower limfaa as Isr es tbe Icnees. or «ven to tlie feei. 

1 wfUntTsr Ibe nun is felt, sad wfaeleter imjr be its degre* frf eerahty, 

•MM iMywiMUjbt diatiaguubed tPT noting Ibe iaa e eee to tbe duld'a 

fori wbMi be oioth abont, and tbe relu-i be etperiftnrea wben be 

Soveifaaa^ bowemr, slow cantious movemetit msy be mede 

. riMsJiMM ; for if tbe flpine he brmocd up and itcadied hx the nir- 

rijiiwlr^, Ut(T imtifnt mny be abto to nioro aurfollT ulwul viMi- 

:ii)iiiK-Hliii[^ max jar to the TertebnU Mcgmvtits. But movpiucnt 

ttlinrt till) rhilil la tnk*ii nl n diwulvantage, witb tbe sptual tutuoles ivUsm], 

te »twArii <lliilrt«aUt([, aod llierofuru it ia iinjxirtuiit to iiKjoire aa to tbe 

•Axil nl oougUnc msuiug, riding in n cttrhngf, or muking a hlse step in 


|l*iti(|f>a pikin, nnotbrr lrii))ortnnt iDtUoation is obtained br notinnf; the 
ii»Ktf»- of mobility retained bv tlio Mpinal seKmentfi. Tlie cUild bolde faia 
ifciMili ■liniy. unl nntiile nil movcmoDtH wliidi necetisitalo bending of the 
'Utin, wliriti kill dnvrii tin biM back and told to f^ft up, be does bo 
luniin({ vtiiwly ii]<'>n liix IiiiikIb and kncM, l[«cpiiig Lis boob sCnigfat; 
and llii'ti K«ltii)a turetuU; on tti hitt foot If niqiurvd to pack up a smull 
nrl iclii fi'iiii llid floor, ho tiinijt Mi1rwii>'ft to tbe ubject sud luwerauiid msus 
liiiriM-K Uy baodlDf and atxai^bumiii^ bis kiieoa, keeping tbe ^une ittraigbt 
aiid nliiiiiirt ereol. Moronmite hucIi at tb«ee an of great value, and in 
di'iibldil I'iMOM itin cliilil Hlmiild Iw put tlimii^h a nerie% of exerciaes. so as 
til t»i"l lli(.riiii(/lil_v (lie iiiuliilii^r of Iim TPilelnra! cidimiu. He diotdd be »- 
i|iiintil Ut liini niurul (|iiiokl; ae be wallcB, to olimb a dinir, or to toucb bis 
I iMM wllb <iulitl.n'<<i)i<>«L tin^^ftni wbilo liw kiK^ee are elntiglit 

Aiititlinr tiiipuriHiit nviiiptoiii in thif attitude aaeumed bjr the patient 
whnii itt n>»l. 1/ llii-ro bi> tiiiu-b diMinm of the boues, tbe cbild will en- 
dMtvoiu- Id rvllew Um H]<iii«i by ■upiwrtiug his bead or diverting Uiu wcigbt 

of tlie body from his buck to hia nnuK Thus tb^ fiivourilc altitude of a 
chiW whcM M-rvicnl vcilebi-ir nre ntlctytflil is to sit wilt bin oHjows on the 
Ubie mpportiuK his head witii Ui» hnnila Li other cnseii of the (lineiuie 
thf wfisbt ot the body U traiiHniitt«d Ihrnugh tiif^ amiN. Mr. Uuwai-il 
>bu«b, ivtii) has devoted much ntti^iitimi ti) thix nuhj^ct, defici'ilM'H two ulmr- 
acterucic attitudos awumod by u child tbo tiiibj^t of carios oi tjio dur- 
aat and luiobor Hpiuea lu ouo of these hu pLoooi tiie pabas of hin liimdo 
CD a choir, and Ifuns over fonvunlfl u-ilh hia artnH tdrotght and Khouldera 
raiMcl. By tliig inr-jinK w^-i^'lit ia taken otF tht gpino and trnii(tiiiittj>d 
throatjb the armii. Aiiothcr iiusitiuii is cc|UiiUt c)uu-acU--riHtiL'. Tliv child 

treats bis ireii^ht on nne toe. witli the \wiel idif htly raised and the knee 
JScxf^ and plnciuf; his hand on tho luiddlo of thtt thi^h, Iciuih over, so ns 
io convey wii^'ht friitn tht Khmildcr down thu arm tu thi- limb. 
Att«ulioD to the above points uiU give rerj' valuable infi>nnatinn. 
Other E^'mptoms are lean trustworthy. Tlnui tondenieiw on prr-jwuro ovor 
ttlA iqptDM of tb« diaeOMxl vcriubm; ia tiomvtimcii prcncul; but it in uut 
dtaraoteristic of rart(^». Striking wilb tlie knuckles don-n tlie centrt.- of 
Uie back Ih a very fallnDiouii test. In cnHea of undoubt^tl eiuieE there may 
be no reeponse ; and a cbil<l may nliriuk wLcn tbi- 8)>inv ia titpped evcQ 
Ifaottgb tbe bones are houulL bi Ibe inunc wny tii*; iipplioution of u hut 
fl|x>itgs to tbe xpiuv KM n ti-Ht of teiideniewi is unaitishicloiT,-, and iu the 
cas« of a child hitlo informntion is to he gaine<l b^r this meana 

Wbenever minal cartels in auHpeclcil we 8L<julit nen-r forget to look fur 
iliar or pmaa absces!< ; for iu cxaen uh<<re tbv uki>ra1iun in limited to tbe 
nuiacv of the bodies of tbo v^rtii'bnr. mi abweau may form before any 
earvnturo CAU b« detocted in the spine. 

CastniiuH o/ OlandK. — One of the most fiimiliar coniie^iiencea of the 
^^BcrofidouB dintbesis vn n chronic nnliir^oitiniit of the I^iuphiitic gliindK In 
^BaU rousg aubjeetA tWi-it ^landi* arc Uubic to eulari^o upon dif^bt irritation ; 
^BbttC in a Ueulthy couatitutioti tbe swetling subsidee when the aiuite which 
^■.(•re riw to it has paHHed away. In the child of Berofulnua tendenciett the 
^^ oraae exciting the morbid procesK ni.-iy bo no feeble and tranaient oh to 
aacnpB notice. Hut, Ihc luibcaUhy action onco SL-t up ruiia a protracted 
coune. ami the uulargcmput cuntinurH until nome furtbtr cbaii'j:^ Lnkea 
place wbioh cnuseH it t« diaapppar. Tbe stcpa by wliicli tlie aftet-lt'd gland 
MCM&es converted into a clie<.-t(y mass h.»vf ubvady been desciibed. The 
proceos ia n purely loiul uue, aud dues not ncwuHarily produce any ill 
•flbetnpon the patitiut. It is evidence, no doubt, uf u constitutional ten* 
dancy. and as Bu<h may excite apprebcnuionD of other and more formidii^ 
Ue mauifefitatioQs of the diutbt^lic ftalc. Of itnelf, howercr, unlcsa the 
•wollen glanibt be ho situated as to press iujiirioui^ly ujion ]mrta in tlie 
neif^bbourbood, or to tbreaten by setting up iadiunmation arouod to injure 
^^s rital organ, it i» wldou attended with danger. 
^H The gLvoda niuafc mmnionlj affected are tbe cervical the bronchial and 
^^tho mesenteric. 

Chronic enlargement of the c«r\'icnl glands is excftssively common, on 
Sioooaut of the many sci'ofulous lesions to which tbo Lead and face an 
Ualile. But these lesions do not all act with equal energy- in promoting 
the glandular awcUing. In Hum mat ion of the pbiiryngwil mucous nieut- 
bnil« ia found to pnjducti lliin lutiiilt fiir mora fr^(|it&iiUy and readily tlxui 
aa trritaut ot^cupying any othci- pint uf the bead and face. A akin nfTcc- 
tioD QMv eiist for & long lime without eauaing enlargenieut of tlie glinda. 
but a pharyngitis caiuien them to enlarge verr quickly. Chronic ghuidulor 
aweUingg are seen oa round or oval moaaes, Qrm to tbe touch, and uHiaUy 


fr€«ly movalile. T)ie dkiii over tbem i-etotss ittt Dorinal colour aotl is not 
lullit-reiit. Tliej «rt' trfiicn»lly to be snen bchiiid tlie ear, lx>iieii,tli tlia 
lower jttw. mi«l sotiititiuicK est«uOiii[; dowu t)ii> neck to lJi« nollnr hmm. 
TL« mnsees niay bo (onued of sinf^e clAiids ; but inoro oftcD ««iiei^ of 
tbetw unite luin are bound togethpi- b^- tliickcned and condcnned cellular 
tiwue. Sucli gwfJlings may reach the n»» ot a lannll npple. L'suiillr. 
oftM* a time, tcndonieas Iwf^s to bo noticed ; th« Bkis b<-ci>mf*s lullterriit 
and i-ed ; flnctuotioii u felt; and frrntiully tlie nbeceeB bumta and dta- 
chargett ila contenta exteniallT. Scrofuloos abac«me« are slow to heaL 
Ofteu a discbarginf? cjivity ia left from wliicb a Hiin putt c»icn|>«H ; i>r the 
openiBfc eolarfrcis and wo wn a KlutrRivb ulcer with duckcned underuiniHl 
edgPH. tu b»d cases BCTeral of tbeee ma^ lie seen at the same time at each 
side of liio nr-rl:. 

Kuliu'^c-d ccmeal p:laiids do not ajwaytt Huppurnto. Somctiincs, after 
remainiri)^ a viu-iiibli> time an a chain of indolent swcUin;;*, they begin 
grwhially to diminish in size and return slowly to their nonniil diniensiouB. 

Ciu^ation of the bronchinl gUindn ia little leso* nomnioa than the same 
condition in tbosu of the neck, llic ciTuct, Lowervr, of such diseaM Ul 
Terj- different. Swelling of the ttiipergciid glands of the oecli. nlthongh 
ansightly enowgh, ia jet iu itself n ootuplaint of comparfttively iitUe 
moment. But wlieu ilie glanda of tlie xue^ttiistinum become ouUrgod, the 
ooriseiiiieuces may he serious. The i^Iaiidn rire wate<l at the bifur«-alion of 
th^ ti-Huh^, behind the upper bcme of the sternum, and a little below it. 
They also dccompany the bronehi into the interior of the hiiig. AVh^^a 
Bwollen, they must tberefore encroach upon neighbouring piirtu, and mny 
proiltice ronaiderable diaturbniice b\ prewang upon the blood-rcascls, the 
air-pnaiuigcH, and tho nerves of the cneat. 

Btforc describing the m'mptonis produced by thiit mcnne, it may be 
wniwrked that enlargement of the bronchial glands doia not nc<ce«Barily 
injply the existeiiee of chronic lung discjiso. A (iliil't is not to be con- 
sidered couMumptive becaunv his nicdin»liiiAl glaudx are bigger than they 
ought to be. The term " bronrbial jihtlusis." whicli hns been applied to 
this condition, is very miBlendiug, and was givi-u at a time when all 
chronic changei^ in the glands were attributed to tubercle. Scrofulous 
children, who are so prone to sulTer from i)ulmouar}' tatarrb, will cenendly 
be found, on car«fnl e^caniinatiitn, to haro some swellings of the gliuids be- 
hind the dtenium ; but if no dnlnesa or bronchial brentliing con be do- 
terte<l over either hnig, we have no reason to infer the «xi)rteQcc of 
pulmonary disease. Like tho siinie affection in the neck, caaeation of tlie 
glands below the trachea is often a purely local prneoaa. inducted in a wi^of- 
nlouB child bv some punning irritation. It is niore serious than a aimilar 
ooudiliou in oiLvr ]>iiJ-tH only 1ii:i-uu.-h- tho glands are shut up in n closed 
cavity, in (he inirtiediidi- in'iL-'idjiJiu-hood of birjie vessels and vital orguia, 
whiih iij:!\ li III!), fill iniui iiiidly by Uieir presaure, or by pathological 

cliaiigi's L iri'urniM4- iti 1 hi in 

It is possible tluit tlic broiicbial glands may 1>e, aa most, atitlioritiea 
hold. occBsionBlIy the seat of tubercle, although nrguineuls in favour of 
this new, drawn esolusiTelv from morbid anatomy, are of only secondary 
value, But Uiere is little doubt that tlie onlinory form of glanduhir en- 
largimoLi ia due to a very diflV-rcnt cauae. It ia* true that children wlio 
suffer from this form of scrofula are frecjnently feverish, and that llicy aro 
often thin and ■under-noiirit>h«d ; but these i>b«nomena arc not neces^rilj 
tlie result of tnl>ercle. It will be generally found that the pyrexia is not 
a conatant feature iu the case. It occura now and again, the chikra tern- 


pnaUirc in tbe iiit^rvnl being uonnol. nnd Uebt ou esr]i occaeioii for a 
■mek or ten days. While tbc frverialmens conliiiuefi, the vhil<l is luinuid 
Bad OKHwa, enta little or nothing, ami in generally troubled with cout;li. 
1ii» (•xpliuiation ia ttuit n child BufTenii^ from tljiK ctushosin is excei«iVRly 
Mlisitiv« to ohnngc« of tempcntttirft and ron/liiy t.-ilic» cold. While the 
ratarrli UkIh he is lowriali : i»nd hb idl Ihu luuraius meinbraae« arc c^iiiaUif 
seiinitivi!. the stODiach siiupathizeii iu tii« (jeiit^ral derangemeut. For llie 
time, then, notritiou is iu abeyance, and he loses Heah. Kvon when the 
attack iH nt lui eud, outl uppetite returuH, Lhe hIoiuhi.:1i duui not tUl at once 
TVOOTer its i»ont<r. Tbt- jjuticul!!! J i^jtstiou couLiuueti weak unil mimot 
fnUv aattsfy tbe rei|uireiii«uts uf Lik systuni, no IJmt he rb^^aiuij deiih but 
donly. If the catAnha recur at short intei-rala, tlie cluid ia kept thin xod 
weak : but lie ia not therefore tidierculiir. aud if he die, he dii-a ii!<iiiilly 
from a siiiipte bmucbitis or pnouiiionift. uud not from any tubercnkr coiu- 
plftjot But «ich chilfiwn. if in a positioii to receive all the care they re- 
quire, Heldom do di^ lu my est>erieiiReHUcli a t^^rmiaatinii \a mi'e in ra»ra 
wbera the LiingK are uttafTecteci. Wlien dii« pr«caiiiioiiH are taken, they 
often become fnt aiu) Htrong, and tlie RigiiR of glandular enltirgt^iuent diit- 

lu luany casck the diaesM in the gliuidii is aasociatod with pulmonozy 
phthiida: but thiK ih more ott*n than not of the non-tnl)ercuW variety-. 
Wltea death tokee place in such cattea it retmlts troai the long dtBeaee, ood 
tbe gUudular sweUiDg'contributca little, if at nil, to the fiitol 'uain: Death. 
bon'OTcr, does sometimes occur lui a coiiHUqueuce uf tli« »crufiiluiiH swell- 
ing. The mass may cause ttuch disturbance by pretumre upuu Doighbour- 
ing parts that inflammation and ulceration are set iip^ aud the child eiuks 
from exhaiwUon. Tliu}i the oBaopbogiiH or an air-tube may be perforated, 
aa in a cnso publisboil by Dr. Qoe, witliout any 8aft«uiug bn\'ing ocoun-ed 
ia the gUnd. In otiier caaea the eland softem uud becomes converted into 
a mass of pas. Here then in hectic fever, general nnd pcr»i»ti-iit niuit- 
iog. and loss of Htrength. Eventually the abHceHR diHrliiirgeH itiu-lf into the 
plouml cAvity, into a brnnrhuR, or into n largn veiMel, i^Uidng fatal haanior- 
rlu^e. A common turiuiiiutioii when Koftvuing bikee in the gland is 
hy acute tuborculuttia. Tliiit, Luwcvcr, may occur in the case of any other 
softening cheesr m&tw wherever xituated. It in lui proof that tbe ghutd 
woe origiaallr tiie seat of tuhernle. 

Tlie Bpeoul symploiiiti produced by enlargement of tbe mediastinal 
gUuidH are tlie cnnaequence of prcKNUie — the glauds by their unwontetl size 
encroacliing upon the parts nroiiiid. 

Preasure upon the eupei-ior vena cavt, or cither innomiiutte vein, inter- 
f«mi with the return of IiUkmI to tJie heart There i» a certain degree uf 
liiidily of th<^ faon, the nkin oinuiid the mouth has a blui^ tint, and tlie 
U|}a k^k pid^' and dark. Xhu mi ]>crli(;iftl vciuci also nrQ uuuctually vitable 
in the tcuiplctt. the nock, and over the front ut the chi^st aud Khoultlem A 
amall amount of presHuru ia sulHcient in vluldren to cause tUlatutiuii of the 
Tenona nulietea of the oheHt, and the symptom ia one of the earliest indi- 
oationa that the bruuctuul gliiiidH are larger tluui they ouglit to l>e. If 
there be great olMttructiuu to the return of bluud from the bi-nil, osdemn 
at the face and pufliucati of the eyelids may be eoen ; aud thix, when one 
l-iunominate vein only ie preesed upon, 13 limited to one tiide of the fnec. 
On Account of the congestion of tlie tciiouh Nv.ttein. r-jiihtaxia is cummoD, 
and haemorrhago iiinyfn'eo occur from tlm luiigti. Hut liifmoptydiH in chU- 
dren ia difficult to detect, for hlood coming up from the air-tiib«H in al- 
> im&Hably mralluwad, while a diacborgo of blood from the mouth is 

nis£ASE i:r canj>K£it. 

iimuillir the rons(>quriir(> of epiirtjisiii, tbo blocxi ctHnping ImtkwAnlft into 
the uroftt from tbfi pintcnor nxreu. 

Pr««eure on the m<rvc8 of thu climt cnuM'K hoaracncm of the xok-c unJ 
psroxvsmal I'ou^h which tnayW miittakf^u fur whoo|jiii;;-cou;;)i. Il ot-curs 
tu violeut 6tA. Aitd tiuiutftiiues en<h> iu a orowiu^ itu^pmlIioI]. It ih, hnw- 
ever, Beldom followed by vouitiiiff. When the premure af1ect« iJso tb« 
lowei- oni^l of the tcschea at it« bifurcation there tnsy be, in tuUlitiou, atUcka 
of til «(iiKT_>iL Tbem tav the ordionry " aaUimatJc nUaeks " of joung dbildrcoL 
Sonietitiies larrugtal Kpnna in ii»ltioed, nud loDf^-miitiauMl spoam may so 
interfere vrith tlie entnuioe of air into tho lunpi that the nntcino-fioRtt'nor 
iliaiuH^r of the rheitl b«<<om«H dimiuislied. the wc^ight of tlie atmoajihsre 
forcitif^ tlio irt<>nuin) hiirkMitrdfi liolon' the k'Vt'l of Uip rilM. All tlime pm»> 
ore BV'tQjitomfl l>cc*>iuc prcntly s^^-avatctl by lui ottiick of puliuuaar>- c»- 
tarrh. In onlinar)- <!»«*■» iwvpre symptoinH we only tfcctt vlicn the rliild 
cntch<>(« oolil. If thiH bnppon, the ccHKlilion of tiie pnti^ut bt^coniM alarm- 
ii)^. HiH fnco it ]in<1 ; hi» dy8i>no::n iliirtreenug ; his \-oice hoarse ; his 
cou<,-h viuh-iit luiil »pciHiuoi.lic. ffSi-n Iht-u tho attack iit oft«u uot coatiuu- 
OUH. It occuTH ill Kiidtleu KeizureK wliicb couie on uure, or nioro ofti^u. in 
!h« Jay, or only at night. Tli» altb-ka last a Tnriable lime and creatft 
ni(ii-li iilarm. In uoet instaucen th«ir Tioleutfe abates after a fevi' days, 
and in tho t'ourse of a waak or an the child BeemB restored to liia onliuuiy 
hciiltb, although h« Ib left langaid and mora focbia than lM>fore bin illiio^^a 
III other coaM the ajraptotnt inereaso in eeraritf instead of diminieliing. 
TIic! child stnrta up snddenly in hia bed with trtsring t-yes and a duaiy, 
frigbtAned face ; bin reiqiinitory niiiHcl«R work Tioteiitly, and bis agitation 
and distreas are puinful to a^. After Rev^nd repf'titjnua of theae attaeka 
dvath tnny tnkv pliK-d cithor Huddt-iily, or after a til uf ironvulaiouD. 

The ithyBicnJ Mgim afloi-ded by exnuiinat ion of th* cht^t art- of imj>ar> 
toooe. In miu'kt-'d otweii wo find dnlnflKs on tbc lirKt bone of Ibo stemiini, 
which limy ctteutl for hoiul* ditttnticv on vuch aide and below. Sonjetiniea 
it is fouud to ruiu-li as fur duwuwiinU ns the Imuw of the heart. I bnv« 
never Knix'<M>ib>il in detecting miy didneiiH in tb« bock between llt« srHiitiliK 
Ind«>fl, the result* of percusAion even in front are oft^n nideadiug. Titer* 
may bo tcij rnnMilernble nntl eitenniTe disease in the glnnda, and niiteso 
the masa ia in artnal contact with the wall of the cheat no dnlnen may !» 
ttifMnvfJi-cd at tJio upot. The signs aflbrded by the stothoitoope ore muc-h 
wore truHlworthT. Preanarc upon the lower port of tho trachea produees 
n rcxpiratory Khidor which iNHometimeiiiioluud as to be heard at adiiilAiice 
from the ehest. It is genrniUy intermittent In eitlier bronphus mnrkod 
prenEure may interfero with tbe entrance of air into thecorrenpondinKluuf!, 
mid lead ton <.i?rtnin uinouiit of cnllapidu at the buec Prcmure»urh as thia, 
however, ia exceplioiial. and in only aeim iu ausen where the tmhtiyemenl is 
great. Tlie kiuhI. oommon aiisrtillntorv mgn connaotod with the brc-alliing 
is iHtxlucetl by roiidiirlion, Hit- ^Limu forming an artifii-inl medium of 
communi<-:itio>i l>y whirh sriniid iaconveypd frrim thenir-tuliieH to the chest 
wall. TliJH gives to the breathing a lond lilowiiigoharacter whicb in \'err 
charootemtic. It i* \<^i Iti^'li pitchr^ and tuetallic tban the onlinary blow- 
ing antl raTeniou» breutbiug hi-ard to caaea of pulmonary conanlidntion and 
excavation ; and is most marked at the apices of the lung, exjxtcially at the 
miprn-fipinoufl foasEB. Sometimes it ia heani Umdlr over Uic whole of one 
or both indea of tho cheat. Opening the moulJj genemlly mcMlitiea consid- 
entlily the iotonaity of this blowing <|»ality, and may even moke it oeasn 

PruBure apon the deamndiog rena oira or the left innomiuata vein 




giTeo rise to ft Iium, and on the pulmonori- artety to a svstolic murmor 
beard beat at the Hecrond left inlersiuire But lani; before the ordinary 
signs of prenare on th« vessola nan 1m> di^tpfloi, wn can indupo prewnire 
OD th« vein if thft hronchinl glnndn urt o iilArjjod. This nifjn i« onr of th* 
earliest indtcattoDH of disivnM- in them; (jliLnds.' ThuM, if the- cliitti be di- 
rected to l>end bis hea«l iMidkwards upon lun wlioiilderti bo that his faoo in 
tnmLol upwards to tha OBiling abtive him, a venous hum, which raries in 
iotciunty ucconlinfr to the sue and position of the Auultcu ^hiiuls, may \ni 
heard vritb tbo 5t«thiMCopo i>hu!e<l U[X)ii thi^ uppt-r bont> of tijc Htcrtium. 
Aa the ohtn in slowlv d(!pn-Hs<'il aj^ii thu Imin berumea lesa difjIim'Uy aiidi- 
ble. and ceawfl shortly before the bend rtachea its ordinary position. The 
«xphtuntion of this piienuiiieTion appears to be tliat the retraction of the 
tiltM forward th« lowor fiid of lb« tnicbon. This winri** with it tha 
^_ lyiDf* in its bifurcation, and the left innomicnte rein is compressed 

"Wlier? it poaaea bebiml the first hone of the nteninnL I believe tJiiH ex- 
pbuiatinn to be the rorreot one, for in cnw* of merely Hat ch*'«t, wh+rc tJi«<re 
IS no raasoQ to suspaH pnlarRcmnnt nf tho ginudB, thfl fiipfirinient fidln. 
Nor. ■fCMD, c*li tb« hum bo produced in a h«fUtby cliild bj the thymus 
gland. This fflnnd Un» in front of the rein immediately behind the stcmmn, 
Knlarped bronchifd Riands he bphind the veanels in tlift bifurcation of tho 
tnkcbaa. A tnrflling in front of the TeiMM>!s does not nppwir to be nbio to 
set up pressunt upuu tho rein nhou thv liciul is bent ba('k«^FU1lM in tho 
position described. Again, in order that tlie exi^eriineut Klioukl nuooeed, 
the lower end of the trachea muHt nut he tited, and the ginudu lying below 
ita bifurcalioi) niuat be movable, othermfle uo hiiiu in hfard when the hmi 
ia rfinirt^d. Thii!* a child was adniitl«d into the East London Chilibva's 
Hospital fur lymphailptiomn. Tliero vm« duhiess at th<> upiwr part of tbs 
slemum. and downwards as far as the base of the heart. In this case, to 
my grpat Hurpriiw, no renoiia hum ronld be hearrl. The child dind. and 
on examination of the body, yellow, tlatt^n«^l. cheeky maaseR were found 
adherent to the inni^r nido of tho Ktcmiim, nii'I othent, vrn' lart;^ and ini- 
Btovable, wero seen filling up tho interval between the bifurcntiona of the 
traobea. The lower end of the iiir-tube was held firmly down by the niaaH, 
mnfteqiiently preasure conhl not be hmught tobearupm the vein by !»end- 
ins of Ihehtttd, ne the t;;htndn. lyin^ Gxcd, could not be bruu^ht lorwai'dit 
B^inst the \<;»8<tl. The cxpcM'inicnt may fionictiuicH fail .even in cases where 
tbo lower end of the trachea u itli its caseotiH ^diinilii Ik free to move, for the 
reliitive position of tlie glands and the vein may not correapoiid ; but an a 
rule it will surx-^^, and a vcnoiiH hum. to inditrcil. is, I b«Ucve, a ccriuia 
ligu tbat the ^landtt of the niedi^MtiiuuQ are not h«altby. 

The me^ni''rii' ijlanda are, jierhape, U'sa cummoiilv affected than those 
of tlie neck or the che^t ; but diaenHo in them is far from rare, although it 
imntiot always be det^^cteit tbiriuy life. Tlie affected glands may be sepn- 
tst«, or they may iinitn as in other idtiintionK into matis^s bound tni^ier 
by thickon<sl c*lhiUr tissue. In this way a mass the size of an appio, aad 
more or less movable may lie fplt nn manipulation of the abdomen. 

The old name for diseaw of the nicsfntj/rip (ilnuds was M/wi ijipjtrn- 
t^nrtt, and rcrj* Bcriona iMnwcqui^ncea were described a« rfi»idtiiif» from the 
^aailulnr mlar^^cmcnt. It is now known that theuo ^mploma art: due, 
Dottn the mesenteric fiwclUnps. hut to the lesion of which they arc the con- 
•pqnenoe ■ and that the Gaseous glands form a part — and often only a veiy 

' Sm aptparliT lbcirril«r, '* Un the Early Diufnotisut Kntafged BranelilalGUniU." 
, £«wM, Angwt H, 1076. 


itmi^iGoint part^if the tlisnuK* from wliicb tfa« patient is suflieriof;. Like 
tL« lymphatic glantlii in otb^t* sifaiations, tliosc of th» Ti»?spnt<MT ew«U up 
hh ft i-(!Hult of irritntioii or indammHtion in tlic porta from whicu tlif Iviti- 
itie T««8eU piwuilg thi-oiig}i Ibeni tak(* Uieir origin. In Ktruiuoutu mi)>- 
^Is they hftvo tbo samo pmnenraK tut the othon io hotxime (luuvius. Of 
nemselvM they fona ft etrong lurguiQCDt Mgunst the tubdvuUr tlieor^- 

fulous gliuiilalar enlurgeineDt ; for coHeatiou of tbi' inewi^uteric gUnd 
leM their mr.a \k tmch that they prcns upou ut-if^^bboiiriu^; jartft, iti in 
A by 110 niftftiiK Aoriou.t matfcr. In orditinrv oases, wlii^r*; there is 
so nccotn|Humiii; kiiiuii uf the buwoK lli« t'Lild's nutntiun ut guud ; his 
spiiitA and ajipetite are satisfjuiorj-; litH t^miNjmture is nonunl ; and ex- 
t«ept, perliapR, for autne sUgbt pallor of face, he may hIiow no sifni of 111- 
lienltli. In lavtA cnaea, liunx-vor, swelling of tli« t'lttuds, if at oil cooaidtirft- 
ble, ix conibiutfd with Ht-roftilouM iilc«mLioti of the bowels ; but uvea hera 
tha ooDBequeucea are nut ulwava as seriouf; as uiigbt be expected. Much 
^"EipeudAupou whether or not the ulceratiotkof the inbefltioe u aooompmiicd 

a caUurbal couditioii uf the mucous memlu^ne. If tluei be prtaeuty 
. . ier« in (linrrbiva with iiiarkvd disturlxince of nutrition. Hie child grows] 
thinner, paler, and weaker; bis expi-wwiou ia diirtrcjwod ; h© sUwpa biMlf ftt 
nij^lit, often asking for drink, and in disturbed by wandering abdonuoal 
painH. Tlie teinpentlure may rifie ali^hUy in the eTcning, imt there ia 
aeldoui mnrkfd jim-icin. 

If tlK'm be uu tutestiiiiU cjituirL, tbu bowold luay 1>o couliued, ftud the 
eSuci upon the ctiild'H gcacml liL-altli is niiiL'h k-ss ])rutiouiiced. He still 
looks ill, ia troubled by flatulent paiun, and is pnla and weakly : but nu- 
trition may bfl fairly performed, and the ehdd may even appear Btout, 
olthoiigb to tbu tonoU his limlm feel soft oud flabby (see uioemtion of 

When caseation of the (glands to HKUocinlod with luhercubu* peritonitia 
— and it is to this combination tbnt ivU old dcHcriptiuiui of tabee meeentehea 
apply— tbe sytiiptoius are those of the peritoneal disease, and the cttue is a 
vvry eeriotut ou«. 

Scrofuloiu) mesenteric frliui^i* ^re not nlw&yn easy to detect Tbo belLy 
is so often <liHtended In children, with ilattileut nceumulatiouH. that it may 
he dilHcillt to force the purietc's auSiciently iiiwunls tu reiuh the HWolh^n 
bodies. MoTOovt-r, n eertaiii tensiun of tlie abdominal wjill, more or less 
Tohintary, nmy sfilJ further tucrCAse the Uiffieulty. The enlor^^ed Kluntl^ 
lie about tlie iniddk- of the aKlomcu, in front of the apine. If the luutts bo 
a large one. presRing the abdominal wall direetly inwards will uNually de- 
tect the HwelUiig at otiee. In cttar^ft wheiT the inerr-iiw in size r>f the glandl] 
is iucunnidu ruble, il i» better to make presaun.' liitcraUy, hrini^ng the tumtllj 
uiogeUier from the sides towards the ventre, so as to catch tlie litUe 
'■"between the lin^re. 

If the glands are large enough to preea upon the parts urouud. there 
may be redema of the lege and Hcrotuiu from preasure upon the vena cava., 
Thin, however, is exceptional. A very ftmall amount of presaure will 
.fofficunt to e&iiftc dilatation of the ei]perti<^ial veins of tbe abdominal wall ^ 
id most cafies of enlarged mesenteric gbuida are nccoupauicd by this 
phenomenon. Crampa in flie legs are hnid to Ite xometimea cauaed by 
preaaiire upon tlie nerves of the nbilomeii ; and fweitet; may be tbo ennac- 
qucDce of pressure upon tbc piHlal rein by the glands ocoupying tbe 
hcpntic uotelL 

Tlie UHual terminatiou of t^erofiUous glands m tlte abdomen is that 
ahrinldng and petrifaction. They rarely aofleji, although cases are 




in wliicb imppnratinK f^kuLln have br^cuiDO adherent to a coil of 
and have iliHcliarged their conUmts inio the bowol. 

Front tite iirei^diiig <!69cnptioD it will he soeu thnt Uio phciiouiciia 
produced by tue ilevelu{)taeiit of tbe ftcnifiiJnutt caubexiii iiru very nutuer- 
oas. Tb« iiuuuf««tatioii8 ot Um ilisthesis luni^t tlivrcfure vary greatly in 
diffeKQt caaes, Ibe uoustitutioiinl t«ud«u»y cxprottKiu;; itself now in odo 
m^TtDOfriniuiother ; for in ndiUtinu to Uiegenei'>Upre<lisj)0»it.i(>ii, tlio child 
Menu also to iiihtrit u K])eoii1 weakneM of pcirlicuUr tintutiK. Thuit. iu oua 
familT wo 80C c-htld .'ifUir dtilil Rtiff«r from MTofiiloii*; inflammation of tlie 
eT« ; m attotber tiioro iu equal sosceptibilitr of the phai-^-ngcal or the naeol 
mocxias membnuiefi : in n thin) we detect a !«|>ecia1 prnnenewt to disease of 
the boDM or of the jnlntH. All theiw dii«arder8 tufi apt to rnn a t«diuii8 
«oiirw and to rvKist treatment nnth Hin^iliu- ohgtinncj'. Thoy cu] onlr 1m 
aitaok0d »uoce«afully by umng mtiuis which iiupruve nulritiun, and weaken 
tbe morbid tendency on which the leiuun depends. Until tliis be done 
Euerv local applications uHll be of smail vidue. 

lha<ino<iui. — It limt bven aaid tlmt tMrofuloua leiiioiiA hnvA no apucial 
rlian<-t«-ra whicli iudiailu thf^ir couittitutiotiiil origin. Thi'ir n-al uulnm 
iQiiHt tlierpfur« be inf(>iT(!d frain tbuir liD^>riu<; ooun«e, their tendency 
to recur, the frequent absence of a&v discoverable loooJ aiuae to tu-couut 
for tbeni, and the cnexiat^nn- of otiier disordem of a like nature, esjie- 
ciflUy of glaiidiiUr fntar({etri«^ijU. 

Til* subcutAneoiiH nbiicoasee mny b«, and oflvti arp, mistAkon for i^'ph- 
ilitiu gutmnato. TJioy muut be diBtin(^iith«d by the bistoi-y of Uio case. 
Doting the complete nhaence from it of any ejiiltililic Hynijitoma 

The diagiioKiR nf tlie ewly Mtaf;e of spinal eaiies liaH br-eii already indi- 
cated in the det^ripliuu of tluit diM.'U»e. Hemcmberiug how the paiu nidi- 
aiea iu thiti atTectiuu tu diHtjint piirts, vrc should always look nith suspicion 

ro pain in the chest or utomneh in a child of ticrofulou» toudeucieti until 
■pine has been tested for tlie effiwt of sudden jars or shocks, an<l the 
dulds attitudes as hu wtdkn or pluytt liuve b«cii in<piired into, P«nfii«tenl 
lain in the occipitnl rt>u:iou. if combined with any xtiJliii-ss lu the neck or 
sny kltered tuimaer of holding the head, is idwaya snspieious of caries of 
the eorvical vertebra!. Pain in thu cheat or stomach, unaffected by food 
l«l tncrenaed by inoTeRieiit and relieved by lying down, ia highly toig^ea* 
ti»of dot-wil eariea. In all cu«08 where spiiinl disonse 13 uuspected tlio 
Afld kHouM l>e mode to miso himself from a i-oourabent position, to pick 
^aamoU object from the floor, or lo climb on to a chair or table, and 
ns manner of peiforniinp these acta ahoiild he earefully obseiTed, noting 
the degree of movibility of the spine, and whether any part of it ia held 

In the owe of enlarged glnnds wff may consider that a gland has be* 
cotM cbM«y if it have enlarged witliout efixleiil cause, and if it ^lersist for 
a longtime aa a painless indolent tumour showing no tendency to subside. 

Caseation of the broix-liial glands may l>e detected in their early stage 
by iht experiment of UitUruing over th» upiwr bone of tbe aternum while 
thseHld'fl hoe<l iu retracted, as alre&<ty descnbed. Dulnewi at the upper 
pw «( the slernuro, if combined with any sign of prtmurc, is vti>- soa- 
pQotu, cifpii*udly if there be fulnesH of the superticiid veins of tbo neck, 
■de of tbe head, and templea Spaamodie bi-catliing and parosysiual cough 
■rtalso ohiu-ftctehstic symptoms — the more so if they are combined wiili 
•^ ilterod quality of voice. In all cases where chililreu hftvc attacks of so- 
iled ■■ aatlim*," attention should be always directed to the bronchial 
tWk (aee page 182). 



In il«* rtw of thi>nif-!»iit«ric glnndfi the only satiBfartoiy proof of 
fiiliuyeiiiwit is lioldiiiK tlu'iii bet.wreii Uie fiupent. Kvtu in llitiH< 
howevE-r. we have to nutiMfv ):iurMilv<-»i tlint tlit- MiiliHtatice ifi r^itllr a (rlaw]^ 
and not a cheesy mass uttAchoiJ to tb© omvulittii, or a luiuu of liart)en«l 
Iii-ceB. C'hfiw^' oiueutal niasecs are much Juor« siiiK-rficial. and conswuitutlr 
niotv f luilv fvlt tLan enlarged glaudB. Tliey ore alao nioi-e fi'eely niovfr^ 
bk'. In feoliii(|r fur mSMntano glandB the fingrni liavo to he pressejf 
down firmlr towards the spine, sua the glands, if enlarged, can be oetected 
09 Rlighily niornble lnm]Ki v>-itli ill-defined moifcin. 

Tlie AciiKntinn couveired to llie tingera 1>y iWoal massra itt T«ry different 
to that fiimiHliffil Ity «nlMT|;e4l f*liui(l«. Fa«iu a«nuui]laljont4 can br rMidily 
studied in c&sc» of typlioi<i fevvr whoi-c tbore is uo dituthau. and the cbilOj 
is taldnt; milk. Here we And elotij^tccl niiuaeit of modemte »iz4' Ijinj^ 
witii their long nxeii in tlie direction of the bowel, and nitunted nt sou«] 
point in tli« counto of tLo colon. Tbey u'e never very ilceply pliicvd, aud'' 
can be fdnnys iviidily rea^^'hed by Hli;;iit <lL-prt»niun of tlit' iiblouiiiinl walL 
Bv tirm prcK»ur« thvy cnu be iii<leQl(^(l by tlif> fiu)^ur. If iitiy doubt is fel(" 
in such a. cat», tlie effect of a oo|aouH enciua should be triwL Ftecal masaesi 
ai-e readily removed by tjiis m«Ant) : whili* liitnps diie to nay otlier cnuae 
are onlv made mnti- evi<1eiit br the injertion ; for llii« by removing easeoiw 
diatentiou nud fiui-al tnnttera, renden a full exploration of tbe nbdomiual 
cavity more easy tlian before. 

Pmf]ti'ms. — It is the exception for scrofulous cliildrcn to die from the 
direct eftecttt of the diwutiw. In fatal caises death lumidly remilts from 
aciito tub(;roulo!«ii« ; tb« outbreak of the tubercular malady being deteiv 
luincd by st>itic tQyatcriouH procvne of infection tbrougU Boftcuini; clieesyl 
inrttter or slowly ulcerating bone. A^aiu, children tue aubjecto of thia 
dtatbesiB are more Rensitive to the ordUiury uluBeK of iU8es«e. Tliej catch 
oold very rciMlily, and tbcicfore ait» apt to auSer from vnriouti chest affec- 
tions. ThcBO. besides their own 8pe«-ia] daiit:er8, iiiav lead to eWl conse- 
quenoes by cauMint; eular^emeiit and cnm-ation of tjie brauelual glands, 
Pneumonia, again, baa a risk of its own in its propensity to undorgo only' 
partial aliftorpUon, aiul eo to induce chronic changes in the Iuuk- 

Scrofulous children are tiiiigiilarly susceptible to the influence of contA- 
gioD. Faw TOch children expo9e<l to the infective principle of zymotic di»- ] 
aase will be found to escjipe, unlesM protected by a pi-«viou8 attack. Such 
diaeaaes, too. have a K|tecial power nf intenmfyiug the diittliiitic taint They 
leave tlio chill not only depremicd by bis late UluesN. butalsomore exposed 
than before to HuScr from the coiiM^qucDces of hid constitutional weakneag. 

KnlarRcd bronchial glandH. if BufEcicutlyatlranced to cause Beriou»prci*- 
Bure ujjoii pnrts amimrf, must always occasion anxiety. If tlien:i be lividity 
of fiice or attacks i>f <l^-spii(C'a, a Ter%' guarde^l prognosis should be given. 
Still, when placed under faToumble coudiltonH hucIi cJiililnm often ilo nciL 

Enlai*g«d uieaeuteric glands, if ubacc<)iii)mnied by idcendiou of bowels i 
or ingns of tubercular peritonitis, art- iu Ihemgclres of Iitlk> importance;. 
If eii^ns of iutestinal ulceration be present, the com in more Benoua. and 
the prognosis dejMiKU nytoa the amount of diarrhon. the preaence of di»* 
eAM in other orgnna, and the eObct of the lesion upon the notritiou of tb0 
pntient TIus subject is considered in another place (see page 665). 

jVmrloid dineaae of organs set up by chronic suiniurotion is of moment, 
an tending to induce an»>iuia and lower the sti-etigtn. Still, in childhood, 
if the priman,* siippuriitioii be nrreKled and the scrofulous dineaae removed, 
tbe amyloid dugcucration often undergoes a surpriedng improvement (ee* 
" Amyloid lirer "). 


TWatrnfrtl. — Thp (viTifttitiitioriiil toTnlcnj'y 1« sproliilouB iMtona is 
attaeked by monwircs wiiitli «iiix)(im;re iiml miuaLniii healthy uiitntio! 
Ttm caiuiea wbicli t^xi'iU^ tli^ <:li>nu9iut (-!Lc-)i(>xt.i have tieen stated to be e 
posure to ocJd ami tkiniJ. inuiiffifieiit. itiid uuHuitiible food, initmra air, ai 
wnnt ol exercise. It is therefore evident tluit a cai'eful i-egulation of the 
dirt. couibiii««l with via-m clotJiirig nnd dnily exercise in tlie open lui'. miui 
be tbe Gi«t iii(tfti«ur»«i to tw kdopted. 

With refiard to fowl, th« child should be fed liberally ; meat, fre^h 
•ggs, sud milk (ihonld enter htrj^oly into hln diet, and his stomach shmihl 
not be nverlo(«(1pd with piiddingH and starchy luatterH to Lhe exclusion uf ^ 
more elriotlr nonrishiiif; articlen of food. Weah vci^labliwt aro n vnhinbloS 
addition to hhf dietary, but potnton must be tnwu with cituLiou, ulthoat;b 
they afe not to 1m.- vitiinly exciudttl. If ihc ti]ip4.-tite be prior, a mnall 
ftmonnt of fitimtdHul is often of «ervit'<>. and the rliilti shoulit be allowed a 
IjDod M-iue^LaaHful of sound claret <li)ut«'il witli au e<|uul iputatity of 
wattr to hirt lUutier. It is TifH>tllp*< to my thiit cakes and mwucI luuata be- 
tween ni(^« must be strictly forliiddcn. lu th» case of iiifaiitK bom of 
ecrofulous pdreutM, « bwdtliy wi-t-miiNe uhoiild be provitled if the mothor 
be unable to suckle her child. If tliis he impotisible, the uttuoitt vinfiiiuic'o 
mutrt b« excivispd in the feeding and genenU niftnayement of tbo baby. 
I>inM!tion8 »]■«• given nlsowhern for tJi« hoiOUiy rcariiij; of irifAiita and tbo 
j^ajiBT is Tftfcrrcd to tbo chnpt*v on " Infantile .-Vlropby " for ftUkr inforum- 
tion upon this iniportunt nubject 

Clunate is a matter of ^reat moment for chil^Iren who are, or am likely 
to be, the subjects of scrofula. A bracing air is indispensable to the euc- 
c o agful tnvittuuut of iliese oases. Rt-sidbnuo in low-lyiu-; clay uoils docs 
muoU to encourage the predisposition, while sandy or ^Tiivelly places, with 
A dry air, are of the •jrwitcst litrielit in iiicreiisiii}* tlie vifjuur of tlie consti- 
tution. On (tceoitnt of the tendency to catarrhs in this lUatliesis, a dry uir 
is of es))ecia1 iitijiortance ; and a place which is Rntliriniitly wnriti during 
the winter rnontJiH to allow of thp ])ntieiit pnssin;^ s ]nt<rn p:u-t of his time 
out of doors is of the ntiiioRt Rem'(w- lArfje townM, with tboir smote and 
vitiated air, are btwl resittoHcca for sc!-ofuh>iis t^hiidren. Wion comjielled 
to live in cities, care sbould be taken that tJie rhiltl is warmly clotlied and 
sent out as much as possible for exercise in the large o[)on spai^na witli 
frliidi incwt towuA are now provided. For children of both Hexes iiealthr 
oat>of-door f^^mcs shoidd be cucouniged ; and they should 1h' early trained 
in suitable gymnastic wxeroisw, nioh a» develop Uie inusule« and expand 

Tbe dtin nhould be kept perfe<;t]y clean by a daily liath, but cold 
doucbea ars often too deprertsing for such Hubj\vt«, unless employed ar- 
cording to llie plan recommended for delicate children (ace Introduction 1. 
T\\f Iwwt^la must bo altondod to. and habits should be iuciilcntod of re^n- Oic use of the close-stool, WTien aperients are required drastic 
purgntivfs should iie avuitleil. It is Iwtter to finploy mildly aclinp ^IrugK, 
such as the compound litjuorice powder, or to combine im aperient with a 
tnnic, as in giving the iufusioii lif ncnna with the infusion of gimtiiin or 

In trcAting children in whom the cachexia has beootae developed, tits 
■bore nuttora must lie carefully iitt«iided to. Great fltn'Mi shoulil be hud 
upon the value of a suitable climate in aiiling the ehild'a rei'ovcrr t<f health. 
If possible, the patient should be sent to winter in a drj- air sbeitei-ed fnim 
cold wimb). Tliere, dr<«is-d from head to foot in warm, woollen clothing, 
he ahoald spend the greater iKirt uf his time out of doors. Cod-liver oil is 




!liai>UEN. ' 

iifnmllv pre«cril>c.l iniliwriiuiniilclj iii th«e cues, an<I while some L-liilJroD 
uppmr tu he ^(rciitlv bL-iitfitc-d \ty Uie prescriptuin, others itteeta iikuost in- 
HvuKible to its (ifferis. It toiiT bin laid ilonni tut n nilo tlint Uie btuut Hcrofu- 
loiu clulilren arc nut Lh« l>eRt loihjccUt for coxl-linyr oil. It is the spare 
fmned chili] with ati nctive, ovrroun s^'stvia whu dcnvtrs moHt benetii from 
the Qse of the ilrb^. The oil Hhauld Lt.- gtn>ti iii ilosett of one tenit]x>ODful 
two or tliroe titavH k <hi;,\ aiul ita u»e uiuhI he coutiiiue*! for tuoiitlts to- 
gether. If th« child appear to be naiiaeated hy tliw cuikBtiuit dneing, the 
oil miv; Ih) reniitte<1 for ik few days «l a time, but miut bo Khortly resumed. 
On the Coiitiii«Dt much vmltie is attached to aooru cofTe**, luiulc liy matttiiig 
together a mixture of aoorce aod coffee besiiA and ^Tindiiig thotu in the 
uroal msmicr. This collee is geDertdly ^ren as au wljuuH tu the oil It 
is esperialJj rproiumended in caau ulttire tliert* I'liutK » chruuic cutorrb of 
the bowelx. Cold bathing, when employed nitli pn>i>er precautious to ia- 
duoe a healthy reuctiou, ut of mat itupoHance in the ti-cntmeiit of moDj 
cases of scrofitla. Tlicse prpoAiitioiiH are deiKribed els<-wli<-rt! (see Iutn> 
docUon). Cold dniichiiip in most uiinful in the caw of stoul t'liiklroo — tbosa 
TCho derive littU- licnptit from cod-liver oil. 

Fur eolni-Reil Kcroluluus ^UudH. hcKidoii the al>ore {general trentmentt 
ioditie combined with iron itt rery useful. I am in the habit of prescribing 
iodide of |vntafuiiini untb the tartrate of iron and glycerine, as in the 161- 
Inmng misturu : 

Jj. PotiiH. iodi'li 9ij. 

Ferri tartai-HLi 3j- 

Olyccriut | se. 

Atjuam a<1 i iT, 

M- Ft. MistiiTO. An eighth imrt to be taken three times in the day. 

The iodide Bhortld he given in fsir doses. The above in suitable to a, 
child of liTR yeoTK of (h;c, aud 13 belter than the onliuary syrup of the 
iodide of iron, tlie .■mfciir uf which is ho frcipwutly fouod to disagree. 
Some pmetitioners prefer the eomiuou tiuctui-e uf iuilide, given in doses of 
thi-ee or four drope freely diluted %ith water. 

Violent attackH uf ilyeijiin )'.i from pressure of eiiUrged glatuls upon the 
non'OR of the nbest aix best treateil at the tinitt by strong countei^irritauta, \ 
After the attack has subsided f^'utlor counter -iiTitation may be eontinuesL 
I liu^tj thought heiietit li^s been derived from the i^rcful and rootiiiucd] 
use of the iodine hiiimtiut to tlie front of the ebesL 

Knlnrged cenieal k'*'"^^'* *'^' sometiinen reiluped by rubbing into them 
twice u day tlie caditnuni ointment of the British Flutrmacopceia dQuted 
with ail etpiid (jtmtitity of I.iid. Tlie oleate of ineixMiry snire is also of ser- 
■vice. This rippliculion Kliniild l>e used of the strength of Ave per cent It 
must be smeai-cd on tlie purt, not rubbed in. It can be used twice a day 
tor tie first live days : then id iiiaht only, aud afterwardH <>vety other day.- 
■When the glivnd Rnp])iir.iles it sliould be opened with as liltJe delay ai-J 
poseible, in order to avoid unnecesssiy scamng of tbe skin. It is im- 
portant, honi'Tcr. to nnticipttte the sii]}puraliYe process, if possible, and 
avoid the dmifien* of a. chroiiic <liftt'liai'giiitr sore. Tlierefore if the nie»a- 
urcs adopte'l to eauKe abBi>i'[)tioii rtixt 8«en to exort tittle iuflueuce upon the 
aise of the swelling, it is advi&nblo to coll iu the aid of tbe BUreeoo> I^r. 
OMbnl Allbiitt atrongly atlrorates free im^lsion and enudennon of the 
eaieoua matter ; and Mr. Teolo tttates tluit lit* has sueco6«fully tFE«t 
many such eases by acoopint* out the oJieexy contents of the glan^ merely ' 
leaviug tJie sound jKirtious Viith the enclosiug capsule. 


V mfteitiitg hoil taken plnoc and tbe ahwesa fonnnl n^nlinn<« tn dis- 
cbarf^ and ofMn ninfiamcs. tho aijthUr odnunUtrAtion of et powder cod- 
tiuniii^ one ^^raiu of hvilmrgi,*nim cum t-rctn to rit;lit jmuus of pcroskle 
of lion is often attemlMl witb HurprUtQ); benefit TUb jiuwiltr nboiild 
not be giren loti;7er than for a week at a time. Tbi> milpmde of cal«iuiu 
is doaes of onv-tii'tli of a gmio, )p%'«ii «ren,- two or tiiree boun, U nlao re- 
oonunetKleil. Tbia. liowevvr. in a very uacertfun rvinedv. SometiniM it 
mooeeds, but mora oft«a it (ails conipletelj^. Tbe chloride of calrinm iu 
doeee <4 five ^nuuB every four Lours is sometiioee sncoesiful. Au ioi' 
portnnt point in the treabiient of enlarged ceiricnl irlaiids is wanntli. 
Z>aring tiie whol« tim« that lootl ttp]>lieatioiia are beiug ummI <be awellin^ 
riioold be earefoll.r prat«H;ted from the cold. A goo<I plan is to coror them 
iriUi a Uiick pad of cotton-wooL 

Ijpgol ' baa spok«D highly of todtne in nil foniks of Mrrofutoua lesiotm. 
He naed tbe drug as a mire to the 8n-«Uiiigs, as n. lotion to tbe ulcora, as 
an injcctiuu tu the aausee and fistulous sores, and as a butb for thv euro 
of the adft^'liuua of Uie skin and subrulaneniiH titoiueH. Iodine tincturm 
and ointments are still fnvoiiht^i appUcntion-t to idl (•Inndular enliirgements. 
Thev should be usmI, howcTcr, ■with caution. I have seen surious slough- 
ing 8et up ic a clutd's ucck by the too energetic inucctiuo of on iodine 
ouitmvut into the skin over a caseous gland. 

CUrouic discharges from the various mucous smfocea are best treatad 

»witli nstrisgent injections Otortha<a from caturrh of the ntiditory mea- 
tus, if limited to the part outride the tyuipauuxu, is readily cured by ibe 
Uktving lotion : 
^ft 8- Boracis gr. t. 
^H Zinci Kulphntis gr. Tii> 
^» GlTcerini Si- 
Aqoain ad 5 ]. 
In usinf this application tho possogu muitt he first lhorou<;hIy cleansed 
hy iujertion with wann \Tater, and then half a <lr»chm of the lotiou must 
be poured into tbe ear and lUlowed to remain. This con be done two or 
three tunes a day. It is important to cure a discharge from tlie enr as 
qnickly as jiosdble. Tbe old notion that otorrhcea in diildren stiould not 
be ehdckod too quiekly is one which if ucted upou may bare serious con- 

* n« Mrength ncomineodsd bjr Logol (er kla nlv« wu : 

9. lodinii gr. tJ.-«, 

PolM. tedidi 3ii--lT. 

Adip«» ..^.„ Si- 

Por his lotion or taijMtlaa: 

B, lodtnii fj. j.-lj. 

Put**. iMn» ■ rr. ij.-ir. 

Aq.<lMUll»tj» Xvilj. 

For lib iMth, for tlie use of s cliUd : 

B. lodinu 91]. 

Pwu* lodfdi 3(?. 

Aq. dMtllUttt q.». 

DtaoIVM ovapleulv and add Ui tbre« gallong of watvr of tlw t«iRp»r»tiir« of OS' R 
In a wooden nnuial. Thii umn mIuIIuu ha T«cainu«U(b aa ft fwneDUltMi U> Krata[ 
Inva latlona and aona. 



AcTTK tabi^reTiInHifl ih nn acuta febril«< goneraJ diseaaa which uiaes, in 
moat CMes, 08 n ^^onnoqu^iiee of special lierediUry |ir&di8]M>sitiou. The <lis- 
fotie vxprossm itself autitoiiii rally bv the fonuBtinu of llio tiiiliury uixlule 
kiiuwn AM Uio f^nLv f^niiiul»lion in tfie rarioiu orgsnsof Ou< body. This 
nudiile ia in gr^At jiart ati <nit-growtl) from Ui« Ij-mphotie eytAeai, and may 
be fouud wherever l^iupliatic or lulenoid tissue nomudljr exisfai Acute 
tul^rcuhwiii i* not to b« ronfoiindetl with pulmansr^- phthioK Indeed, 
the tu'u uJIttctious fiTA esMDtiBUy iliatinct. for ulremtion of the luiiji;, xl- 
tbouifh occaaioaaUy pweeilt, i« by no nicftna a npcesftory jxirt of the tuber- 
cular proRfisa 

In the young fiiihjef^t. acute tuben-ulofdB frequently iuisiinK« a form 
wliirh in ntrr in tlio lulult. In rUilcUinorl tlte rliwnRo not iinooiiimonly 
prL*iiut« itflt'lf iw n primiiry febrile oiTcctiou, ni\-iu}' riwi to but few nyinp- 
toms. and those the luimifoatutioii mcrtly of the Reucral (luitre»i without 
any sign pointing to local nu»chi«l It is often not until a few (IsyH be- 
fore the doso of the ilhjuas that any Byuiptoms are diiicovvred to draw atp 
teiitioii to any purticular orpui. This is the primary fonn of the diaeaac, 
wlticb hait much the cUttrut'ter of an ii<nit# spMific fever. 

In other cases, almost at tlie Kniue time with the b(>^niitng of the gen- 
eral !tviii)>tomN otheint, more or lens mveie, lu-e noticetl, slioi^iug thut some 
}Kirlii.-iiljir orj^iui in expucially fasleued iii)<)ii by tlte tulierculur pFOCaoi. 
Thi» form in out uni-ommon iti eases of tiilx-rciilar uioniRf^tia, 

A tJiinl fonii re^eniblef) tliat vrhiirh in ofteu met with in the adult where 
the di»eaAe ai'ines ait a set^ondary aflection in tbe couree of some ntlier ill- 
ne«8, ajid ill HHch a case briiijjs the life of tlie child quickly to an eniL 
Tiu8 form is seen when tuberculosis snpcrreDeQ upon empyema, i>ii«uiu(>- 
uic phthisis, etc. 

Acute tulwreuloaifl attaelcs children of all agn, and mar be seen in -mj 
yonn^f infanta. W'lien it onc.ura at this early age the luutoniical feature of 
the iliticuHo is always very wi<Iely distributed. Ou tbe otJier bimd, tlie 
older the child tbe more litely is it that llic fommtiou of the gray gruiiu- 
latiuu will be limited to Bpeuiai cavities of tbe body. 

Tbe wunl " tubercle " lias been and instill employed io ao vngue a 
8cn»e by various autliurH tbnt it bos almost censed to convey any d(^nit«, 
meauiuff. It may be well, therefore, to stats that iii the foUowiog {MgMI 
tbo word is in every case iisexl to signify tbe roihary Doduk called "gray' 
)j:nuialatiou " in the adult, but which in tbe child veiy quickly booomes' 
yellow and opaque. 

Caumtion. — Kcroditary iiredispoRition pln\'8 a very important part in 
the etiotot^ of tubuLX-idutjJs. In a lurf,'c pmporiiou of cases a oiatinot 
fiuuily t«^ndeucy to the fonniiUoii of tul^-rclc i-an bo discovered. The t«n- 
deno}' is not, however, always exhibited in the jnrents. These are often, to 


all ttppcftrancffl, of somid coostitutioti. It maj ho ueceseaiy to pusb our 
inqmnefl foi'tber l>ack iinil ask tm la the lif^altli of tlie graiidparentit lunl vt 
(■oliat«raI branchefl of thi> foiiiily. In a i^hild uith thi» unfortiiiiiito ]>r6ili)«' 
pat^ition, an; cnuiu) wliicli impaint tli4> nutrition of tlir^ Ivnly may oxoitfi tbc 
intmiffjttutiuiiH of tli*- tubcrcul^Lr tcuilcncy. Tborwforo lowcriiiK complaints 
uid iusBoilury ooDditJuiui genondly ai-e lastly regarded lu tuLportoni agent* 
in the production of tuberoiUcMiii. 

Tliere arc certain acute »i>c<:ilic uialiMlies with which the luborcular for- 
matiou ia ler^' npt to ho oMtoctntul. M'liu(jpiii(;-oougb tuid mtiibleM tuny 
bo Kiid to uuinber tub^rculoxut uuioDgst thtir M4|uelii-, t»o txfimiiou in it to 
find children ronTiUencent (i-oin these complaints, who are placed under 
iiiiravotirable oonditionft for complete recovery, fall victims to tiie disease, 
Tj"j>lioid tevw is 80iiietitnrtt folloued by it. Cliiklrpn who nulftir fmiii mal- 
fomiation of th« hetirt wii.1i ii:irrowiii(^ of tlio pulmonary uUirj an nluo 
rary liable to bocome tubercular. They do uot, bowovcr, often sufier from 
acate tabenruloHin. In tlir>ui thi^ dineasf! is more apt to asHiuno primarily 
the form of chronto tuben^ulnr phthisis, even if the distribution of tuber- 
cle bc<-onio aft4>rwarilB gcnornli8e<l. U'hr.n the prcdispositiim ia Btrong, 
noy catuu) which (iivcti a nhock to Uui HjfMtuia, nuc-h lui a fall, a blow, or 
other Kiiuilnr accident, muy be tnifficient to cxcit« the outbreak of the dl»- 

In addition to the cusea tvhere tuberculoeia ia excited iu the bodies of 
persons prPtli^Kuwil to tlie alTection by febrile dL'tturlmnceit or tmwhol^ 
soma oonditious uf Life, tlieTe are other iiiHtanoeti wlier« tlie diseaso appoara 
to be set up by a lo<^al iDfcctire procest. It h»» booa w«]l eetabUabed 
by utimeroim esperimentcnt that tho inoiuliLliDu of tubcrculnua matter 
into tJie bodieH of healthy miimak will pntdiice geiiemi tulierculofiiH ; 
and it in h«l<l by Koch and bin foUouei's Uiat the infoctinK af^ent in 
BOeb cases 10 thr luiuiitc oi't^uiiiHiu kiiuvk-u ob the "tiibeii'lv buicillus." Un- 
til lately it was WUcvud that thv iDoculiitiou iiilo a healthy uuimtd of 
noD-tiilM^rt'ulnua or putrid miitt«rH would giw nue to the (uriualiuu iu the 
system of a iKxiy indict inpuahable by the microscope from the gi-aypranu- 
latiuu. But recent iiivesfiji^tioiis have niaile it B*ideiit tliat mine fftllnf^ 
mast have been present in the experiments wliicb appeared to establiso 
thi* result ; for a repc'titioD of tbe cxperimentx by compotent obaerms 
bsTv ahown that no ill couseqiiences of any kind may follow tbe intra- 
(luction of sucb niattera uuder the nldii. Still. aTguments drawn from 
experiments upon aniiiudi^, especially u[>oii the rodentia, wliich are unudly 
ael<&ct«d for thene iiivesti^Uonit, are not perliaiia HtricUy apphcuble to tho 
htinmn subject. In man tlte premnce of scfteniog cheesy matter in any 
part of the )x>dy ntay >ti^t up au infeetive proeen whieh iti iiidieuted by 
fever, waiting, an<l iiyniptoiiiH of j^onoral diutroHs and eventually by Bifjns 
tndit-iitiug inipUciitiou of Hpecial orKfiia. After death a pciu-nd distribu- 
tion of small ntxlulea wbiiJi have all the characlerH of the gray grniiiilatioQ 
ta found in rarioua orj^ana. In children a chroiiit* empyema often ioduoea 
such a ci>ii<litiun, and thu child usuitUy <lifw with tliu nyiuptouis of tiiber- 
ralar meoiuj^tiit. Acute tuWrculoKiA may be nlHo xet up by other forms 
of chaeay degeneration. Softening enaeouB gl;mdH and uh^esy pneumonia 
are oommon exeitiii;; cauace of the dineaae ; indeed, the aorofuloua habit of 
bodr appears iu ititflf to be n favouriu<r iuthietice. am) tlie iiasues of such 
■ubieets furnish a couj^euinl auil in wliicb tlie {growth of the tul'ierruhw 
bodicfl «m be readily eYcited. The share taken by the tubercle bacillua iu 
the production of tubnrculowt—wliether it ia tlie sole mndium by wbiiOlr 
the infectioQ ia conveyed, as U mnintaineal by some, or is merely a oMoi 



mlditioii to the septic n^nt, aa ia belieTsil b; others — w fltill at the jimt- 
oiit moment n mnttw of warm debate. 

Jlurbvi A'lafoiiiij. — Tbe diuthbiitioD of tlie gray i^nnulaiion i» very 
froijtieutly ^'4rTii-ml ill the child. Iii the iiifautiLis abuottt alwavMoo; in 
oldf^r rhildren it iuhv he limited to ou4> or more cavitieti of llie iKnly. 
MM. JUlliet luid Bortb&z have coiomeuted upon the cuzioua fact that whiJe 
in tlie adult, nfcrTdiiig tn LohIh' rnnon, it tiiben'U- esist anjwbem in tbe 
body it will bn found nlt«n in the luugH, in t3to chUd 1b« ivttffii snm^itu&t 
cxcape ultoffothor althon|;h <-v«it oth«r port of tlio boily iit attackfiL 
WhfQ fniiDu in ontr cavity of th« body kkmo, tho part afl^Mited ia lunially 
tJiC! akuU or tbe atHlomeu. 

Tlic pray graniilatiou is n firm, pmv, translueent, projootiug nodido 
which viiribH in sisc (ruin a du<r piu'e h«od, or t-vvu s smaiiirr objct't, to a 
millet seed. In childnu the colour vt^ry (juickly chaugos to yirUoir and 
the tmnsliK^ence diaapiwans so liiiit wiinto\iT orgiui is euuuintKl pray and 
yellow uodules (the loiter usually prt-doiDinatinpl are found mixed to- 
(jetber. Tbe fpowth ucfiira, ar<'oiiliiit.' to Rindfl^^iHcli, aa the reMilt of a 
i!]X>(^'ific- irritati<^iti of the eudotheliji- nf thf lymphatics, tbp senniK nu-m- 
branee, and the blood-ressela, mpeciAtly tUd fomi«r; and tbe niklulee are 
found to follow the mniificntionH of thi- fiut-r urtcneii because the lympbo- 
tioa mn cliieSy in tlie ailventitia of tlie blood-veHMeU. On careful exami- 
natioD the miliafj* ImmJicr can be w>nn growing upon tlie fine vemela, in- 
voIvinK the whole cahhro of tho channel iu the tonuUvst arteries, and in 
Uiow? a dcpree larper fonmnc protiibcmnrea uu ou« aide. KUidfliiHch <Ie- 
HcribpR the grannie aa a prmluot of iiidaainiHtiou. and HtAtm that it consMts 
in an increaaiog n^oumul&tion of leucocj-tes in the connective tiHsue of tho 
part irritated. Uf thcao wliite m-118 a jKHtioo talte on an epithelioi<l char- 
actor. Tlie»e grow to three or five times tin nxe <if a ■uliite blood cDrima- 
cle and are cnlled tubercle vvUa. Others develop iiiln tlie irregular 
bmiicbiiig Ixxbes called " giant-cella." Tli* giant-<'oIla are not, how«Yer, 
a» was at one lime mipponpd, peruliw to tuberrJe. SchCppel believes that 
they arime within » Mooil-vcsKel from tlie aecumnlation and wlheiuou uf 
tenaciouH miuwcs of molecular ninlter. When tliey bnro reached a size 
which canHt>a distention of thn vcswi-l, nuclei be^iin to appear. According 
to this observer, tbe epithelioid cell»t are derived from pi-nccsKa of tbe 
giant-cells. They lie ai>ound the latter and constitute the greater part of 
the nodiilc. Aci'onling to most observers, n Miction of tb« tuberclee, alter 
tliey liiive been home time in cxiKtenco, ahows n delicate reticuhtm, the 
metthes of wliicli contJiin the cella. Thin, however, vt denied by others. 

In proportion ntt the tubcivular body enlarcee by Accumulation of ccUa 
the centrRl port in fuuiul to degenemte. anil when exaniiucd at thia atage 
((.('., after degenerntion haK iK'guu) it will be seen to couaiitt in great meaa- 
\ire of Bmall, Hlirivelled, and granular cella. 

The preneiioe of the gray granulation in any tinmie ia usually cjuidcly 

followed by intlunimation in tjhe oeigldtourhnod of the growthii. In tbe 

case of e serous membrane, Kucb ii8 the meningee of tho bmn or the peri- 

I'tooeun, lymph is quickly thrown out, and, if time be allowed, becomea 

.OMeous. In the Iuhrh an early ronnequence ix bronchitis and catarrhal 

'p&enmonia. In theae or^^an-i the graiiiilea vei^ quickly become yellow and 

cflecoue, find cvor^' »tiLge of degeneration of the nodulce is usually to bo 

discovered. Br. AVilBon Fox has dcncribed in tbe lungH of cJiildren dead 

Irom tubertruloHis : gnkv trantduoent gnmulationii ; opaque white grau- 

nlee — aoft, but of varying finniieEis and renstanee ; tlie aanie, but can(>nu<i 

in Uie oectre ; >*ellow grauulutioua, verj' aoft uid emdly cruahed ; checaj- 



granules— ilrjr, t^tiiip, mid friaUr, witb or witliout aHurrooDiliiig zoii« of 
gnr transpArciit lojittnr; i^^ifM o( tho latu-r forminp: little maaHeK ilie 
axe of a pea, Wim, ur uix-n ^uhiut ; ioduratod ^igiucutctl ^mQiilea, tangle 
or in groupK ; unci, Ijuitly, tnictx of Miriable Kua luiJ irretfular outUoA, 
gnuiiilAr on the mirface. pwHiu^; inHeiUiiblj- into the so-collect " gra^r infii- 
Intioa." Sometimcii, itbo, lie notioe<l Uttie cavitieH from Boft<'niu(;'of tlw 
tnberculw uuuntM. TbL-iii w«re. in uiidiliuu, si^'im of secomUrv uilurrliAl 
pneumonia au*l ita cuiiKuqueiKMM. 

Ulceration of lana iiiid the furm&tiou of caviti«B is not a common con- 
aequuDCf in eiu-1; life of aciitt* put]iioiiiLr_T tiilierculoMK lu inftuibi in wbum 
the ditMunw nms » »pif^l ooiirw tliis legion in ri>rv biceptioiml. It in. liow- 
evBT, aOEuetiii)«*i mot uilb. TIiuh, iii an iulitnt, &,^•^^^\ i'i>;bl. inouthB, with 
lour teeth, who «li&d iu the Eaai Lotidou Cliildren'ti Hoepitnl of arule gtti- 
vnl tub«rrulc«ui4 ^tb fleonitdary bmut:lio-piieuuiort ia and nieuiiigitiit, tu- 
bercles, gmy ftiid v«ll(iw, vrarv (ouml after dt^itli ocmpviug all tbo caiitiea 
in tho body. Tbt'y w*ro diwcoverctt at tlio bow of tlw bmn, on the peri- 
toneam, in tbo mibntjuic-c nf bho liver, Kplvcn. and Iddners. The lungs vers 
rompletely xtufTed with tlipm, ami in the lower lol>e of the left lnn({ n lunalt 
e«Tily hiul inrmed of the «ze nf a liiiwl-tiut. Such n condition iit, however, 
nut rouimon. Even iu olik-r I'liildrcu, lUtliougb the dunitiuu of tho illnees 
IN longwr. bn-ukiug up of the luugfi, aa a cunsL-quenoc of acute tuberculoiiiii 
is Doupimitivelv nrely mwii. 

In the iJiff-Wi'UM the gny and yellow grunulntii>nA are seated ^spMddli) 
in tlie siualliT liowel, aiirl iiivohe priiicitMLlly the ilium and the part of too 
CKCum in the ueij>hboarbood of tlitt valve, 'llie nodules lie in the sub- 
nmcooB tiaxue, and in the a<*ute fonn of th« di^enMe do not, tut a rub?, give 
liaa to ulceration. In tho li'ir Uie tubercles ore developed on tlie AmaJlenb 
KsmiflcAtions of the hepatic artcrry. Tliey mar be miPti undd- the serous 
eoat, an<l an^ nlxo foiuul in tho iitterlobular Kpoortii and in the interior of 
the iobnles. They ara usually few in niiinber. In addition to l>einF; tbo 
seat of tubercle, tho organ uf often found to preHOTit otlier patbokiRirBl 
eharncters not especially dietinetive of the tubercular diaeaHe. ThuR, it 
may be enlart^ed from a simple hypertrophy or from fatty infiltration, and 
is aoni«tim«B the seat of a oirrboQe uluuige. Iu the latter case it may give 
rise loaacitea 

The nUwn \» one uf tlie organs most commonly attacked by tubercle. 
Gtay fuiu yellow erooulations and Lir^'e cheeey maeses may be found, »o 
fchftt the size of the orj^'an ia eonftiderably increased. In the hyintrya mili- 
Bry iiOilulcA may be* thinly tMyitU'roil throuf^b tlie |iiirenchynia. The Uttlo 
maMca are developed, as elsewtwn^ in the sbeatJi of tho Rimilleitt arteries. 
Botnetimes mora estenave disease im met with, and liu--:o mat>Hcrii of cheesy 
UMtter are formetl whi^b soften and jpve rise to I ulM-rculaus ulcera Tliem 
may ponetntte deeply into the reiiul tiRHue. Aceonliug to Kiudtleionh tbo 
diacam.- bcffios in the papUlarv portion uf the ii^likud. spreading; from tho 
loaeoas liniug of the caliceN. In extreme caaea the kidney i» eonverted 
into n tliict-walled sac, with horaiapherical prolmainna, ea«h of which ror- 
raspoDids to a. .VUdpifrhiau prrnmid. 'Iliv bla'tkr is somotimeti iiivulvcd, al- 
though coiiipuratively nwely in early Ufu, Miliary nodules appear iu the 
ntbmuooua tissue and soften, giving rise to euinilar uleent the et^lgea of 
which are found on examination to be intiltrnted with closely paeked gray 
and yellow gnutuUtiouh. 

til addition to tlie lesions which hare been mentiooeil, the bronchial 
and ueseatoric gkudg ore always eoUt:ged and choosy. Somotuoee they 






>iaBABB IK OnTLnttEIf. 

How far (lio cbci>»y iimttcr, nlu<-li is ofU-ii foiiuil in Iathv c|uuntittM 
te mon.' prolon^vtl chmmi of jjuliuoniuy tulieri'iilosix. u lu bv re^^tuxlei3 
tiiboi-i;u!ar is a ijueetiou upou vrliick oppoeit« opiuioua are held. Virdiow 
ftud his followers loolc upon tOi sucL cawoua uatter aa tbe couaequeDce of 
I'OntiUTlial pii«uiuoiiU; ami tliere ui no doubt that the miliar; liodulu is 
priniHriLy wi »xtnt-nlvc-oUr growth, while tbe rmteoux iiiarmk, eavh as ure 
foniul in (>h«4>«v piuMimonift, Ukf> their orifrin froiu n proltfcntioii of thQ 
epithfliiil EletUfiilti it> the aii--f-pIU. Before thf ^iaiit-rcll was laioWD to 
W n iitiiHtitueiit nf other thaii Htrirtly tiilterniliir ttlriiclunfs, tbe preMDOa 
of this, eell w»H hnlil In l>o eoiitiniiKtory of tho hilM'milHr natum of tt^ 
patbulotat^al iiroduct. Nuw the prcscocc of tbe bacillus is considered \}j 
many to jmitit to the sonio conclamon. But is the questinti one which can 
be detertniTipd so I el r upon anatomical f[i-niiinls? ilip cliniml history of 
the discii8<< is sui-eiy a not imiiuportAut clomcut in the solution. It is gtn- 
I'ntUy iwlniitti^d thnt the i-luitcrtt t-xamiiintiuu iliHcoTcm in the ;;my (;nuiul»- 
tioa no ])ectilinrity of slructure whichcau be relied uijoii to Heparate 
nodule fi'om other bodies hnving a like appearance, anil under IJie inicitw 
toope all cheeay matter has ver>' aliuil&r duuat'tere. The caae is one in 
which Iho cliuicnl features of tlie mahuly «1ioiihVhnvo an exceptional ralus 
in detcruiiiiin;^' the nntuni of tbe patliologicitl priMbict -. for if two dteeasoa 
are found to differ widely in the mode of oh^^rin of the attack, in thenaturftj 
of Uie HYtuptoiuH. and in the course of Uic iUneas, we niny he«itat« to 
niit identity of nature, hnwerer ulose may be the refleniblance in the uuu ' 
toniicol (condition]*. 

Syii\j)lomx. PrininiT Inlx-rculosi.t in tht; chihl coiiiinoidy awtunii'v tho 
form of !Ui acutu {jL-ncnil diwiwe. It exciU* iiiodenitc pyrciiii and luiukcd 
interfereuoe with nutrition, and froiu tho iiidi<tinite character of the earlier 
«yniptoo)8 and the abaence of any nrnuifesliition of local diatreea, often 
prenenta tn^at dilliridty in the diagnosis. Sooner or later nigus are dis- 
covered jtuiuting to ilitteafle of special oi^ana: cereln-al ayiuploms nxiae, 
or there ar» iudicatinuM of piihtioiiary mi«chter. Tiil^^rciilar mcninpfitis 
and cerebral tubercle arc do»cribcd at length in Kmcial cbaptciB. The 
present description is confined to casi^H where the disease ir general, and 
where the loud symptonia are limited to tbe lungs and other oi^gnna Dot 
elaewhcrt- reforrt-d to. 

Children who fall victimB to acute tuberculosis, nltbougb often of deli- 
cate appeanuicp, are not nerewarily lliiu and feeble-lookinc. In many 
' oaaea tne nutritiou of the patieut is very pood, and the child is considered 
Ito he in everi* way a heAltliy subject until the ilim-asc appear*. It is not 
Lftl nil uncommon, e»i>vri«lly in caises where the chief violent* of the nuilaily 
'is DXponded upon tho ci>iTbnd iiicuiu<{it8. to find thai uj) to tho tiine of fats 
illness the child had never suffered from a ilay's iudispo^tion. In other 
caaes the |in1ient has l)epn iir>tice<l to lie sensitive to t'hills and prone to ai- 
ttecks of iudigOMtiou. Tliese latter children artt ofrcn of fi-ail nppeamnca 
and have the "tubercular aspect." Their skin in thin and ti'anspureiit, 
their hair fine and silky, their featnira rcfrulnr and delicate, their bones 
oinnll, and tlioir ahonlders narrow and slnpiiifr. 

Acute hiberculo«i« inay bcjjin j:n^iua!ly or middcnty. In cxeeptioiMl 
natioB the disenMc bna an iibnipl hc}rinniu<,'. There is htph fever, beadaefae, 
epistaxis, relised or confineil ItoweU, and tJie child ia very rcBlleMS and 
atupid. lint this mode of beiriniiiiiy is very rare. In the iiTf^ majority 
of iuataucc)^ the onset is so insidious that there is a difficulty in fixing upon 
a date for the beginning of tbe attack. Ilie earlieri^^mpl^iws. u has hecn 
sold, are so slight and vague, and the child passes so gradually ijom health 



In sickneHB, that Uie mothDr U iiminllj quite unahle to clet«nniii« whtm 
sill? fimt notioeil any signs of iudisjMtsitioii. Shn will say tiuit for itniiie 
weuks tbt: chilJ biul i»&eiiie<l to bo Iv-^d brisk ami lively tbiiu vriw lus M-ont ; 
tbat be woulJ ofwn lie nbout ituU.-iMl "f pliiyiiifi : out! tbiit liia nfipetite 
luul aeetneil to (nil : but timt uo Rpitcial iiuiK>rlam.'(> wits utlanlMHi to tlicHo 
)(TU)ptoiii!< uutil s'>in«lliiDg iiiL>re tletitjite was Dotic>eil wliit-b «xtit«c] nianu. 
The first iiitUuTuco o( tli« ()L-*uiv<<- i:t ii[)on general uutritiuii. Thu cbikl be- 
gins to luok paV. witb n. ciiriuiis truiiKuarout jHiDor. His couiaiictim> huv'c 
ft hiaiali tint, bikI the lower eyylkl is Aispoltmrefi He Josea bin ^hgbtli- 
UOM nuJ ^'t>t dull Huil tuopLug: bia n])]>etite in poor, anil be fiUs off in ]il» 
flesh. A uert'iin aiHoimt nt fever usually acxnmpiuiieii tbis contlilioo. In 
tbe ev«>uiuf{ Ibo cbft«ktt mny b« brigbtlT fliiHbod, niid tlio bands and feet 
feel bot tu the touph At thiM tiu« a tliormonM^1«r in tbo axilla morkti !>«- 
tween 100^ »n(1 101^. Tbo patient tH tUirstv. luid often nak-s for nnter in 
tli« uif^bt In tbe mormiis Uie temiwruture la norma! ; but thnehiM vfhpij 
he leaves lii« l>'-il ^enemliy lookn piUo and diHlrcsflf-<l. Tho ftnxioui* «x- 
]iresaioa of thu [ik^c iu tbc-M.- civt:» in indued cuiuiiiuikl}' ii iiutcwui'tby pbc- 
iioinenon ; aiid if coiiibiuml vvitli luililness of tbe gucienil Hvm^tuiuH. and 
«oiiip)et« abHeun.' uf nil sigus uf lufal dit^ctmifort, ia iiu iudicatiun of illnvsa 
of Tvry swiioun uiouiciil. In some ca^es tbere ai'e rc]>eated alttu-k& of chilli- 
ueiM followed In beat ; and these may have a permdicily wliioli siiggesto 
suspicions tbat llic> i-liUd m miflorini^ iroin »^«. Ttio diillinese, however, 
Mklooa amonutii to Rliire>riit|;, and snontin^ is scanty or absent Loss of 
flesh 18 nCTer ver)' long in Rfaomns ilfnelf. Tlie waiting is often ^'ery 
i OTiuluid. tuilvtM finine reloxntirtn of tlie lioiTels in preNent, and in Uie iiiujor- 
hij ol cosM M iutcrmitleiit. In bintpital pnUi'ntM, undor llio unaceustouied 
[SnAuenoe of good food and uurain^, it is uot uDcummoii for a child to re- 
in some of tlie ticsh he bad lost, ulthc»ugb all the time tbe ferer cnn- 
JOM And tbo (^enni-al disease is pursuing its regular track. Kven in 
chiMrAD who ikre livln;:; in better circtunstances the progress of the iilncsa 
lis often very unuijiuvl — Lbv child aootuing to Lo (tltvmat«ly bt-ltcr aud 
Ivom, and the temjjei'attin' llLictuHtinf curiously fruui day to day. Sotu*- 
I'tinws, indeed, Ibe pj-rexin in fctund entirely lo subside, uml for a few i3a5s 
i-tlio improvement may lie such lliat recovery ia confidently anticipaled. 
Tbm iutermiiMtou i» iMunlty, however, of short durttion. nnil tlie jKitient 
relnpees into bis former state. At this tim« a common syniptoni ih (rolenin 
«f ue legs and sometiuiM of the face, aod tbo orioo mav contain a Irooe 
of J^bumen. Id young Imbien the only Hyniplxima of the lUseose fur n oon- 
riderable timo may be (Ji^-ht fever, pallor, some lofis of ttesli, on inelaatic 
state of the skin, luid a little cMeina of the cxtrciDitios. 

For the &ret few wuckH tbe alxivv {ji-ncnil m-mptoms arc all that can bo 
(lisrorered ; and the most cnrt-ful (.'Xiiininiiliou dctec-ls no camw- to which 
tho oridODtly serious condition o[ tlie child euo be referred. He is thin, 
pale, vreukly, and hatleas ; but bis toDguo is clean, aud although feverish 
and restlesB at ai>;bt be slctpn fairly wdl. is not liglit^beiKled, and in tbo 
daytime makes no conipbkiiit. His nlxloiueu is uurmal. ratber tUttonod 
tbao distended ; there is m^ enlargement of the llrer or epleen — at l«Mt 
during the first lev wcvkn of tbe illnciu ; nod prossure of Uie belly elicits 
no sign of tendi'mess. In sr)me eiuw a tv\r rosy spots. iatb«r more red 
than tbe U-phoid spot, and of a larger size, are noticed rm the abd(»nen 
and obest. The skiu geiiemlly in dry and liarab. 

Alter a tiinc luc«l xyinptoain ariw. These oft«n point to cerebral irri- 
' tAttoo. Aa attntrk of coiirul-ions occurs, followed by ttqiiinttug ; Uie ]juml^ 
dilated ; tbei-e i& drowsiuc«i aud rigidity of joints ; aud the chiUI uii 


with all tlio rriu]>UiiuN uf tulifrn-ular muiun^liiL It othor uiKtanc<>a tli» 
CTADial (-■atity esuapes, aud ti^'mpUniis ure uotioed obowiug impIirAboD of 
the lunge. 

The firnt local sign of nrntc pulmonnry tuberculous is cougfa. This in 
short mill li»<>kiiig, iukI in Die «nrli«-r jteriwl not very ^queoL It axay 
bo accoiiipnuieii by fionii' hum' of brouttiiuf;; ; hut the reepirntiona are Dot 
alvrn^VH iiit-reuHed iu rapiditv, luid cvc-ii iit »u (ulTan^eii HLage of tlie iliseaae, 
if there !>« only s iiioilfralt? ainnnnt of ratarrh, iiiair b« littlv, ii at itll 
mart! rapid than in hrnith. Tlio (-ough at Uiix tiim* is not accompanied by 
anv abuonndjity o( phj'sical sif-nB. Itcpcat«i examination of Ute cbrat 
disc^vfift Qrj duInfHs ou pcrcutwion ; aud on oocaHional rlirk of rhouchus 
or iL Kibilant whc^^c ra»y be the cmlv phnnninpnnn pi«.wnl. In some coses 
the cliild lUett without any fresh Brmptonin ; hut usually a Mcondurr broDclii- 
tis dcvolop!^ nflcr a time. Tb«'t>r(-alhiii^ then becouKis mpid. tue face is 
baugard aud livid, aud tlie uai-es dilidt in inspiration. Ttic puis* U small 
aou rapid, aiid thpn> may bo 60w« »ih<;lit pi-niTniion of The pukp-reEpini- 
tiou ratio ; but tliia n«Ter occurs to the dctjrco noticoil in cawrs of broncho- 
pn^unionin. Tlic temperature rises, and may reach 103 ' iii the evening. 
'Siiilcing to l<X) in tlio nioniilig. With the RtnthOKcope we noir find tbfti 
LbrMtli-souiidit covcrod by a crisp, bubbling rltoncbus, Trhidi occupies 
whole L'striit of iHith inspiration and c-xptrution. If the brciktbin^* can lie 
heaid througli the rhonrliua, it in not Im.'iichial idthough the fxpiration 
is pnrh.ip» prolonged. Tbere ie no dulness if collapHe be absent ; but 
soiuftittictt local ciiUapM of tnutiW exleat ix-cui-s at the apex ; and w« may 
tiud II httlc locjil dulnvsK at thf )tuj)i'ii-ttpiiiDU8 fbeeo, or above the clavicle, 
with fiiiut lirtiiu'hial breathing. l^iiTcr is nowhere HO}' iucreatted resonanoe 
of voice or cough. 

Tlie aliove Higns may persist 'without alteration to tlie cloae. Oft 
ihowerer, t)ie iiillainniation ])»»»»« into cntanhal pneumonia. Patches 
duhieeo nro tlun diHCo^eT^d al the niM>x or el^cwhcii*. At theso spots th<^ 
breathing is blowiag or tubular ; the rhouchus becomini nispor, finer, aud 
more cmpilaling in cliaractcT : utid Iht' vocat rcrHonance may be intensely 
brooiciiophnnie. T)io patches of conHoUitation, na in canes of the non- 
tubercular indommation, may cooldsce until large areae of tissue are BOlid- 

The occuirenee of bronclio-pnevuuonia is aUo indicated by increased 
Mverity of thff previouR B\*niptomti, The lividity dc^peuK : the hi^athing 
bsocKDCH lubouix'd ; the ttoft piu-ts of the chest and optgastriuin sink in at 
eaeb inspiration: the nails become purple, and the snperficinl veins of the 
extremitioH ara fulkr than in iienltJi. The tttniporaturr; also rises to a 
higher level, and may reach 104° or 105" in the evwiing, 'Whoii thctw 
Byiiiptoma are noticed the illneHs is ver>- near ite close ; indeed, the child 
Hcldom Hurv'ivtH luugt'v than a day or two. Death loay be preceded by a 
fit of convuleionft, due cither to mciiingitirt or aspbj-^ia. 

A littl*- girl, aged ten, with u coiiHuinptivc fumily history, was a pa- 
tionl iu the l-^t Tx)ndon Cliildren's Uosjiiiah Tlie child was said to liara 
auiTcred wbon quite young from menslea, whooping-cough, and scarlatina, 
but had recovered perfectly from eai;b. although the Utter had been lot- 
lowed by dropsy. Bbe had also had an athtck of agiiu when between tnti and 
tlireo ycnni of age. Still, the chUd had been in fair health until idx veeks 
before' admiwioD. Her illness had begim soddcnJy. but the symptoms at 
fb^ were not inarkoiL Slit; had seemed geuernlly poorly, but did not lose 
ih to any comtidenible extent ; nur waK she troublt-d with cough for the 
three weeka When the cough began it was short and dry, but not 


ng. Three 6a^ before adiniwuoii it hiul brcoiiio Ioom. anrl tUo 
Und cxpectotntod 9om« jroUov ^blc-t<iu. After tlio cougb began lUm 
was noUcotl to wutttc luiii to bo fovenali, eweating much at iiight. Vor n 
veek ber fetit bad been n little xwoUea 

Oo ftdraissioD the child's oxpresition waa nnxiotiR. Tboiv irns aanw 
hriditj of tbt; fiu:e, iiiid in iLc t.-vi'iiin(; bur checks lliuibod brij^btly. llcr 
toQgue WHS r;]eHii and ber Ixmebt regulai". Teinjieratun! lit 7 p. v.. 10*1.4'^. 
On euininalioii of the cbcMt tbe (>Brt.-iiBaioii-not* wiis tJigbtly higbpitcbed 
klwve tbe claricles, but elsewhere vaa normal. ETerj^bere about tbe 
chest tbe breath-flouiulH ncro roiK^nled by a nictullic bubbUng rhoiiobuB. 
This was connuir liebiiid tliaii in front, and nrnupied the wbole extent of 
both inflpiratton and 4'Kpinition. Tlie voi^iU rettononro van uominl. A 
rbmiohal £renutu» could be fell vvvr^'nbt^n: ubuiit lUu cbont. 

After odmuudon the pbj'sical sji^un jjeniisted -viith UtUe altcnition. The 
dulnOM disappeared from the aj>ic<>^H ouil iioiiecoolii be detected elsen-here. 
The pubso was very mpi^l, ISO-IGW; respirntiuua, 60-6y ; t«uj|>eralur« caclt 
eTenuig, lOl""— 102-i^. After a few days ilic li«ditv dw'poued ; tbo (^bild 
becoma rer}- reBtltuw. and xbe died on tbe niutk day — tbe lilty-Orst day of 
bar iUiiea». 

j On examination of tbe body ^ray or yellow miliary nodules were found 

in Che bver. 8i>leeii, and kidney*. Gray gnuiulatious were also seen under 

tbe Mrous coHt of the RinaU intesttuo, and Mvore uunieroua on tbe piu uia- 

ter. Tbe longs were stuffed witU tubercle throughout, and the Qodulea 

f^nued projections on the tturfare uuileraeath tlic pleui'a. Tbe nodnlp-H 

pvsiied in sixo, tba lariat not Rxoeeilii]^ n hempfieeil iii dinmetor. TIi» 

long tissue between tbcm wiut of n deep red colour and tore reoddy. It. 

bowerer, floated tu water. Tlio mediastinal glands were enlarged una 

eheei^, and one or two* were noftened. 

^^ JBMidftA th« ports which tiiLve lieeii mention(>d, tubereulosia somi^tiniCB 

^PinTOtres the urinary' appiuruttiM. Tliu kidiicye iiidve^l are ofU.-u atl'eeted, and 

the cousetiuent cougestiou is iiu doubt » e;iu8e of thv »Ugbt albiimimuift 

. whinh iii a commuti symptom of the uffectiou. But Imiiidi^ tbe kiiiiieys, 

tuberculosia may occur m the bladder. This leeion is more common in 

|tb« adult tbau in younger aubjerl.t. but. is met >vit1i fmm time to tloie in 
tbe older ublldreu. Ax it gives Hhu to luauy of tbe «yiiipU^>iiig of vi-kichI 
«a]culus this form of tuberculoais must not be passed over without a word 
vf mention. 
"Die pntaence of miliary taberclea in the bladder sate up a cyititis, and 
IffivM rlae to Byniptoma wliich ore attributed almoat invariably to atone. 
There is great irritability of tbe bladder and iucreoecd fiequouoy of mictu- 
rition; ami aeeorJing tn Gm'beatd, tliese symptonia me more miu-ked at 
Bight than during the day. .\t the end of the How of urine some pus may 
b* pifiwii. or a drop of blood may nppoai' nt the cxti'omity of the urethral 
ciutkL 'Riero may be pain, which in refercud tu Uiu mgiou of thu bhiildcr, 
and the paasage of mniie is often aeconipnuied by uuea«iueiui. 8<>uietiiuc8 
inieturition is only eflfoeted by atraining, tluriug which the rectma may pro- 
hkpMi. The uriiit; mrty be uontml, but oft^-u ia cloudy and thick. It mar 
OODtun a traee of sdbumen. The temperature and gnneml Bj-niploins of 
taborsolosia are present in Uieae raseft. Kxplnration of the blatlder with a 
sound duKiovets no oalfluIuM ; but digital csuioioatioa by Volkniaun'a 
I method (i.e., pasting a finger into tbe reutmn aud prdputiug with tbe oLlier 
"laud above the pubeo) aometimea det««ta a tubercular nodule at the fun- 
loa of the bbttlder. 

lu tbo stomach, intestine, liver, and spleen the development of tuberdo 






Tfu-t'ly gives rise to safiiriont local symptotus m fiunifib ffrounds for diag- 
iiiMin. Id Die atoiundi the If-niou ute.;/ excite digentive trouble ; bitt even 
tliiH bt mi uncummoii cuuitequeuce of uie iltM-JUie. suA when present in tii^- 
iiilicaut merely of calarrli of the raucous mvuiliruue. Billion, iiitU-ed, baa 
rejiorted a ca«« io wUicli a cUilil died »fter vomitiog a Uree ^uautily of 
bluuil, nnd on exuminatioii of tlie IhxIjt an ulcer niw found at tbe wger 
eur^'aturo mirruunded hy tiiben^ulous nodules. This onso is, bowerer, k 
very cxccptiooal one. In the intcstioo tlte lesion ecoms to excite no sjiut>> 
toiUH wlmterer. The spleen, if lliniiiged with masecH of tubercle, jmy ue 

-Wnl&r^ed ; 1>ut t\iv liver in mi'ely ihrr<-ai«ed in sim from tliis cause. It is, 
>w*ver, sonmtiRiiw tlw noal of fatty iiifllt ration. 
TIiR duration of acute tubcmdoaiB in tbv child ie KtflJom pitdoDK^d. 
infniibt it inn^' bi»t kIx weeliii or two monthK ; in older cbildreu some> 
*bnt Inn^r. Tbe ioDgth of the ilLuctts pnucipuUy depeuds upon the du- 

ImUoo of Uie oarl7Btago, for when lovtd Hyinptoms occur uiowing im- 
plication of upccial orf^aoH. tbe diMiue luooUjr nuia mpidjjr to ita 

Ifiaynonn. — ^'llie disease with which acute tiil>en-uloeis is moet apt to 
be cuufuuudud in ujihuid fover. Tlii» is ett|>eci&llj' the case when tlte lu- 

flwnmlar affectiou begius abruptlr with high fever, headadie. uid bleeding 
{rom tbe noHe. A. dia^oida is then intpoesiblp at Iho flret ; indeed it ia 
oft«u oul^ hy the aftei-coiirso of the illiieee, aud the prolon^^ation of the 
irrexLa beyond tlie time ivlieu iii typhoid fever a full of temjierattuv tuajr 
looked for. thiU tuiKpicioiut ur« excited of the ustitro uf tbo dii«»uie. 
Tbe diAgDo«is between an ordinary case of acute tubcrculoeit and t\-pboid 
fever is fn'^'en elsewhere (see poffo 88). 

SometiiiieH cniieH of acute gastric entarrh may prcitent considariable ro- 
senililiitirc to ftirulc tuberculosis^ in it« eiu*)y ftagd-. Not lonj; agp I vas 
insulted about a bnv, scvmi or vi^'bt years of a^, who had at one lima 

'fluffereil to my own;e from sli(;ht consolidation of the right apex, 
the eousequfuce uf an altacb uf catarrhal jjiieumouia. The boy wuh 
scrofulous type, thin and pale. He n-as naid to have been losing fleab toi 
some time anil to have had a poor npiieiite. For more, tbiui a week bill 
appetite ha<^l been exeeptioiuUly bad : Inn temperature had lieeu ntised, nnd 
he bad bad a hacking eoiigh. I saw the boyat 5 p.m.. with Dr. J. K. MiUer, 
whoso patient he was. The boy's teinpetature was then 100.2\ He uasi 
pale with no flush on hia cheeka ; and liis face ivns bright and lively witlt-J 
out any sign of Jitttress. Hia clie.»t was everii'whcrn perfectly normal, 
except for a little di^- rhoncUus about the back. Uis 1H-Uy was not dis- 
tended. Tlicrc WHS no eiilnrfremfut of the Uvcr or spleen, and no swollen 
loesenleric gtiuids could Iw felt. He lind no sore tbroat. The tou{*iio was 
furred, and tttc hivath liad n faint unpleasant amcil. IIk-iv was no albu- 
men in tlie wiitvr, nor any Inicu of u-dcuia of tbe lcg«. Tlie niirits of the 
child wure sind to be remarkably guoit : and I was told that thut nioniing 
he liai] been ^een attempting the ncrubatic feat of standing on bis head. 
Thia latter fact, joined with tbe bright cxprcHtiiou of the liuy*s fac«, tbe 
ngus of gaxtric derangBmeut, and the abneQce of all emltuce of tnxhnouary 
mischief, ap|)eareit to me to afTord sufficient grouml for excluding tutieiv 
culoaia I acoordingly expressed an opinion tkat the boy was Offering 
merely fixiin u subacute attack of gastric catarrb. Sbortlv afterwards I 
heard that the febrile symptoms qiiickly disappeared. 

According to toy e^'peneno6, children eulieriag fi'om tbe developuieul 
of tuberrie are inTarial>ly dull and npirillctct. uikI usually show signs of 
distnsB in the face. If a boy jumps about aud playa boisterousl.i,, os if he 





, icute tuberculosU Diay be esclnded ■mlh a liigh degree of pmb- 

dptectioti of aculo tiiVH-rruIosin depp^dH in n gront meomire upon 
tfae alNWOCe of K^'iujitotud r;i]>alil<; uf ex|i1:iiiiui(,' i1itY«n>]ttlv the twiriouH con- 
ditioti of the pBti«ut If » rliikl itt brought wiili ii history of ferer Bud 
wMitng of soDie weelui' tluratiou, if tie lookB ill, with n dlatre&iKd haSf^ard 
W». and if a carffut fju«ni nation of tlie whole \iody di^corere no duKOne 
of or^uis, the state of tlie child in f'Mdciitly not to he ntlribiiloil to any 
local cnuM. In 8uc*h a OAse the dia^X'sis w.-ill li« h«twe«ii typhoid fever 
and tiibemiloflis. and if from the. duration of tlie illnenH, or for reanotis 
pii-eii cbimherf! {sea pAj^o S3), t^'^ihoid ferer can be exdudtKl, we ahnll be 
rulueed to tubc-rcnhwdfi tts tlio only otlior probable cxplniuition of the 
child's state. la u biMlly fed iiifftiit who Iiub bwia irreffalarly fcTeriab from 
teething, and whose nutrition has bptn somo time defective, the luMtary of 
wiwtint^ and pjTexia niny riisp liiiijiipinns of tubcrniloiiiH. Hut in Mioh a 
ea«e the child will not look h.v^''ii«l niid pinched lik« ou6 sutToriu}; trom 
that diiM^im- : the irrrj^ulur and oUvn ^mitly eh-vritod temperature of dcu- 
Ution is uidiVo the modemte |iyi-('):i:i nf tlie tubereuhir affection, nud will 
b© safficteotly esi>laine«l hy iimiwetion of the tnnus. Moreover, tlie history 
of the illness, which will alraotit certainly indiidv scrcml attacks of diar- 
rfawA or siplniettti, and the account of tlwt child's <li«t will fiiruuth aii amply 
KuAeient explanation of his (continued iudi»puuitioii. lu an infant acute 
tuborcoloBta is almost alwsrs nt-vompanied by <edeDia of the le^ At this 
period of life tlie coiiibiiuitioii «( wasting, m<Mlerate pjTCxia, and ojdcnia of 
the lower limbs is n very siiKpicioiiH one. 

Kven wh4tn tli« cnse in tirat seen in its lat^r atngf, aft^r fflgna of looal 
die^oae bavt^ boooine evident, the difigiioin« ix not alnikyii uiwy. The pliyni- 
<ml BignH ut tubereiduuH bronehltiK luive no Kpeciol rhonii'ter diHtiiictive of 
their specific ori^iii, and they miiBt be read in the liiijht afforded by the 
hi«borv and coume of tht iUtiewt in orvler that tliey may be righlly intvr- 
preted. lu tubercidons broiK-hitiH the tenipemtui-e id higher than in found 
m an uucouiplieat«d ouse of the cFitiUTbid diHcntrC In niuiplo rApiUary 
broDcbitis the pulmonoi; affection is seldom accompanied by marked 
pyrexia, and tlie meri-ury rarely riaea higher than 101 m the evening. In 
tabcveidnuR bmnehiti«, on the other hand, a temperature of 104° ia not 
uneouiuon. The chief point, howexer, iH the oceurreni'fi of the hronohinl 
diKorder in n «hild worn and weakened by illncaa of iindi'tincd cliariwtcr 
and BCrompanied by fever and wTuitiup. If this illnesM hiive Huceeeded 
■ after u variable interval to an attaek of whooping-ooii(<h or meBsleii, tlie foot 
Alone flbouki mise a suspicion of the tuberculoiu uature of ihi: puliiiouatT' 
ooniplaint. Ho, abto, if brouchu-purumonia mipcrveiie. with Mputa of locnl 
conmlidation. the htMtor}' of prerioiiK ill heiUth is etutenliol to » rtplit un- 
deratiiDdinp of tlie nature of the child'H complaint In either case the 
odkI of s^nnptoins imiuttiit; to iulnK-niniul miwrhief is of Uie titinnet 
valnc in conflniiing our mispieioniH : nud if coiiviiUions occur, followed by 
fiquiiitin^', ptoai*;, uuetpial pupik, luid rimditv of the joints, Iho tubereu- 
loua nature of the disease may be cooaidered to be entaliUahed (hcc also 
pnge 440). 

In tulterculosia of tbo bladder tho eliild'n diRtress is usually attributed 
to the pre«oncc of a Tesictd coloulua. There is, }iow«v«r, one diAgnootio 
potul of considernble importAnce. The irritation exeited in children by a 
atone in the bludder i» rarely a eaune of noticeable pjTesia. while, when the 
fprmptoma are due to vesij-jU tjiberculo^is, the evening teniiiemture may 
nwuh 102' or liighur. Moreover, di^aUil vuuuiiiutiou aitter the xoaiuier z«- 



(SB Ur ClftLDRBK. 

<'omm<^nrlri1 hy TnlkntAnn, alreadj lefnred to, will sometintM <lAt««t « 
tubiTculuuH Dodulc ill the fiuidos of the bladder. 

/Vosfwoaw, — The pnx^iec-lH of n child in whom Acnte luberciiliwis has 
reT«aled itseli unmistakably tire rprj- desperate, lii the (mrli«r stagi^ of iha 
<liii«H0e, whUb auy uucvrloiiity cxi»t« ns to tho unture of th^ illueas, vre can 
trtill bopc ; but wlit-u a M-cutiiiiirii' bix)n<;hitis or nilAirtial pneiimanin ariwe^ 
or ttigiiit of iiitracnmittl miiu-hicf iir<< uoti»ed, deutli iimy lio votsidered car- 
tain, AttiM-kit of ^astrio catarrh iu diUdreu vitli tuberculous tmd scfofo- 
louB tendencies are iilniost: invariably lu-K-ompaiiiet) by fever. If the attack 
i« protracted or ni]«dly recurs, mi intermittent pyrexin niny continue for 
Homo we«kB, and on roeovery tbo child mny b« thotif^ht lo havp passed 
tlirougb an attack of tubfiviilnsis, Prolmbly most instoncctt of oUcgvd 
recovery from acute tulwrculomH are cases of this kind, 

lyealiiifnt. — When a coho of acute tuberciiloBui has ocrumHl amongst 
Hit) yQiiii);cr mcmbeni of a family vcr>' Kpocial measuros ahoold be taken 
to prewr^f tliv lii-nlth of thosii who rfiuaiii. They should sleep in well 
rentilated rooms, be ^^'urmly clothc^l. aud be taken oul of doors n>giiliu'ly 
for exercise. Such children eboiild, if possible, live much in the country 
on n sandy or ^-avelly N>il, nud should avoid tlie vitiated air of towofl. 
Thi-ir diet nthonld be {tlniii, and excess of ((weetM aoit fennentaUe matter 
shoidd be forbidden. Children with tubercular tcndencira sbould not bo 
tAupht too enrly. It is vise to postpone regular education xictil tlicy 
reach their iristJ) or seventh year ; ana every care should be taken that 
their (wnaitive brains are not overtanked. The motJier, if henielf of frail 
ooostitiition, Rhould b» forbidden to mjokle her infant, and a health^ 
vret nurae lihould be provided. Any si^iK of iudi^^crtLion iu eucb mib- 
jects should be promptly treated, and the utmoat. vigilance ahould be 
exercised to maintain the nutritive prouusses of the body at a healthy 

All catarrhs, however mild ihcy may be, abould at ouc« receive ntten> 
tion, and the poreutK should be wiiraed of the danger of trea^g tlid child 
ftfl if he were well before all aipis of his temporair aihneiit have disop- 
peaifnl. Acute disejuies, especially the exiuithcumta, liave iK-ciiliar daugem 
for these children ; and during tlie perioil of co»valeHcence tlie iiatienta 
should ho put into the iiint*t favourable conditions for insuring eompleto 
ncorory. A good son air tihould be ulwn,^-s ndviittid in tbcee coses w sooa 
as the child is well enough to be moved from bia home, 

>Vhen Uie disease dedares itself no drugs appear to have any value in 
arresting its course, and very little in retarding tbc- fatal issue. Home- 
t ilin g may bi; tluui- by trctitiug Hymptoms aud^pitttiiig u stop to euft^bLin^ 
ooniptieutious. Thus the looseuesti of the b(ju flti. which is often an trarly 
srmptom of tlie disease, may be tisually controlled by a powder rontaiuiiig 
three or four gniiunof rhubarb with double the quantity o( aromftlicclialk 
powder every night ; and tivice adayadraugiit coutaLuiui,' dilute sulphuric 
acid^m, iij,-v,), with tinct. opii (m j -ij.), and a fewdrops o( glywrinc in 
ateaspoouful uf water. Sometimes tiie carbonate of bismuth in full <\fitic» 
(gr. K.-XI.J may be substituted with advantage for the rbHbcu'b in the 
powdor. It in spito of the»e rome<lieR the looMtiess Btjll oontinacB, gallic 
acid (gr. ij,-v,) can be given with landanuro. 

It is very ditSinilt to reduce the pyrexia in acute tuberrolobia Largo 
doses of t]ntnine have no more tliau a tempomn- effect, and often appear to 
be quite U8cl««H ; snlifrlic acid and its eompountis liave Httie bmeficiol 
influence ; an<l the hyjiojihoi^phitc-s buve not iu my luindt< been followed by 
satisfactory rcHidts. The bypophospUiU: of lime, however, although it 


do6B not reduce the beat, is usefnl in aUeviating the Tarious forme of 
catarrh bo common in tuberculous cbildreo, and often has a senfiible 
influence in improving the appetite, and sometimes, temporarily, the 

Inflammatoi^ chest afiectiosn must be treated upon ordinary principles. 
As the strength of the child declines, stimulants will be required, and thu 
brandy-and-«gg mixture must be resorted to. The diet should be sudi 
as is recomiuended for other febrile diseases. 


cnAPTER m. 


SrPHiLm in lh« infant is gm«ntl]v the coDwquenoe o{ an inberit«d 
taint. Il tli^u preb&nts a (wmbiuntiou of Die ncM^^Ilect Boooodmrv and 
tertiuj sUf^B of the liieenBP. 8omelim«B, bawerer, it is aeqnirea, and 
tlicre in then n prinmrv lesion as in the adult. In this Intter caae the 
in'iii|)toniD rcwnibin itiorp tlioM' of eonHtitntionnl n^'philiti nc!qDired after 
puberty. .Still, the j>ro>:freM of the diMMt' is not ontirply uniufiuon««<l by 
Ihe tender i^:e of thf jmlicnt, for in iifter-t-hildbooj wc can uflui discover 
manr KTniptoniii nliich are oommnn to tlie inherited form of the niahulv. 

(.'auMtimi. — The congenital taint may bo deriTod from either the 
fiitbLT or Ibv iiiotbur; and tho M-vcrity of t)i« triuiKiiiitt<;d disciiso ie in 
diree-l jjrojKirtioii to the tibortnCKit of the liiUB wbiob ban (rhipwd since ibe 
sp|)eanuic-e of conHtitutiouid ^luptoniH in tlie pareiiL 

The tiiE«aee uiay oiiginate with tli<^ father. In this case much discus- 
sion bs.i arii4cii n.t to tlic mode in which the luother becxKnen affected, or 
(U to whethur hIlo becomox atTected nt ulL lu I'awtt wh^re th«r» is no evi- 
dence of direct contaftion, it has bpon h«ld bv some ob«rnrcr9 that the 
mother qir^ be infected by tainted tqiemiatic Itiiid, althougli no primary 
lesion in produced. Others heliere timt tlie infection only talteo place at 
the timo when couc«ption oocitrs -, otbera, again, deny that even in this 
caae can infection bo conveyed ; while a fourth clan isidBtit that Tchcn the 
mother becomes herself sypliilitic tbo viruH ia introduced onlv indireelly, 
being absorbed into her Rj-at.ein froni tlie Uiiiitt-d enibiTo. Thi« diM'uwtion 
liu, DO doubt, fTTOftt scientilic interest, but is of httlc practical rolue. Of 
far KTSiktor iiiiportuiicc i» it ttt n^membcr thut il miui uiuy bc^et a s^i^ulitic 
child long after ooDstitutiuuHl HvniptomH hiive ceased to nppear in bin own 
p4>nion. Hx«n the researcIi^-H of Dr. KasBowitz it appe&re that when left 
untri'akd, ii Koricii of yeare — nix, ei^ht, ten, or even more — may elApm: be- 
fbiw a man is relieved from tliv obli^^tion of tianxmitting the taint to Lis 
olB^riu^. ^Mieu uiercuriul tmtmeiit. in adopted, the remedy detrtroys for 
a tinie the power of the virus, and the parent is then capable of begetting 
a healtliy child. Put this immunity from ti«iiamitting the diBeaae u* not 
pernmiient. In some cases the influence of treatment becomes exbauRted 
after a longer or shorter time, and the poiBoo recovers something of its 
former vindence. 

* With regard to the escape of a m other who has bonie a syphilitic child, 
it seemii certain th«t Hie CBcnpe nuist be incomplete, for she acquires a 
atniDge immumty from further iufoction. Ivoug ngo CoUl-k hiid it down 
an a canon that, "a uew-lxim child affected with inherited Bi-phili». e\-cn 
oltiiotigh it may luivn Rymptoma in the moutli. never canses uloeration of 
the breast which il sucks, if it be the mother who uucJdm it, although routiu- 
uiDfC ciq»blc of iufectiuK a stnuige nurse." Thia law holdt) ^uoii oh com- 
pletely now U8 when CoUes wrote in 1837 ; and it is difficult to uuderstaad 




bow tbo moUit-r con l>e proof agaiuat the poison uuleBa abe be bcraelf 
Kubjeot or th« tli»eaM>. 

SliU, tbere is no ([uostion of tbo flppnrcnt immunity of idiliiv woiuei 
the uutben of sj^tiiiitic cbildrcD. £>i-. Kamomtz ht» brougbt forward' 
imtanees to prove tlutthe taont careful exttminaUoti, cooibinfil with vratctK 
ing exteiiding ov«r uiooy yeara, mtty fail to detect sigrtBof >t\iibibM in women 
who U»ve borne iUsc*9ed chiltlreu. It c«rtainly docs appear possible that, 
att Ur. Uiiti-biutiiiit believea, a woman ma; bave a forui of <b»entte too ttny- 
bta to '^w rifui to i^xtoi-iiAl inaiiif«8tation8, but strouf; »nougU to itrott^et 
bar from further conUuiiiiialioii. Mr. Bfrkek'v Hill inHVjtHtbat in all 1be«e 
easefl tlw encApe of the mother is not real. lie belicYca, too, tliat iii ntoat 
cxrtv* ttbe hn» r'tntiiu^d s_v[>)iilifl in tbe usual maimer by Jireot couta^OD, 
but ibut Ui4) pi-iiii-ii-y «r>vo h^rn eevapacl notice through examinatiou having 
been tlelayeJ t(>i> lon^ iift«r tlic lUto of infevtiun. U 

Tlifi nintlier a.!ont- may be iliHeosed, the fa-tlier being benltbr. In thisV 
ooae if lilt' mother luive eontmrteil the diHeaitc' slioilly before conoeplion, 
aud oxbibit tbo socomliuy rnAh during lior ]x^riod of f^ostation, tlif child 
proWbly narer ucapeii. If four or morv ycnnt have eUpnud siauu her i 
feotion at the time when slie becomes pretoiant. she may buve loHt hi 
power of trnnnmitting the tliBOHae luid t)ie cluld ma}' be spared. 

If tbo mother hv actuidly pregnaut when thv viruM firet eiitem her ayth 
t«ui. alic m:iy or may uutcotniuuiii<?nte it lo hi-r ofTspriiig. Much dcpi-uda 
upon tbe period oC geatatiou Ht wliirh itifectiuu took pla<.^(>. The iiior(> ad- 
vauoed the disease in the mother before her conliuemeiit, the more likely ia 
ibe infiiiit. to inherit tbe tftiut ; and if a nerondnry raali bare appeared upon 
tbt' molher'K l)oily before the end of her pi'e|j:imu<T^*. the child usually t^iilTerg 
severely from ttie triuinmittcd dj«eA8C. In the initio] stage of th« laahuly 
the power of tha mother to unport the taint is les» nertain ; aud it iB im- 
probable thikt the fffttns ran I>e infert«nl if the [mrerit hare not hnrnelf 
anffitred from coni^tilutioual syniptoiiiu. TLer<>fore, if xhe only contriurt tlie 
dieense ton-ords the clone of bur prctruaucy, the infiuut hnit a fair ubttncu of 
eacnpfc There U no evidence to Kh»)W that tlie disouae Dontriictcd by the 
motiier afb>r the eijihtli month of her pregmuicy can be coinmuuieated to 
the UfitUA ill her womb. 

The iuflucnco of nit-rruriid trt^atment in destroyiug the traDHmiBsive 
power is %'ery decided. If a woman who haa borne a dead or diseased 
eliild be properly trt>aU>d before or during her uext pregnaurv. the inftuift 
Iwriie af{er ti-catuient «tll be either rjerfectly healthy or will suffer very 
slii^lilly from th« iiihi^riied taint Still, aa in the ciwe of syphiliN in the 
fathor, the counts nu-tiug ]x>wer of tbo reiuedy ia apt to be diminished by 

When a healthy infant acqaires the diseofle after birth, it is usually dnr- 
illg IsctatioD, tJte nipple of the mother or nurse lui^inf^ Iveconie infeete<1 
by the mouth of anoiimr <'lnld who (*iiff(^r>i from the diwoawe^ It is doubt- 
ful if the milk alone of n syphilitir woman iu ciipublu of conimunlcuting the 
complaint Again, areideutal contact with H{>erific purulent diachargai, 
wbelhor from a primary iirire or a. AN'oudar^' Itmion, may im|>Art the diwanp. 
lu Utber C4HO the Hore produced lu tbe child ia a primary one. Another 
icothod by which the syphilitic poi>ion may be ronreyed to a healthy child 
is by Toecinatinn. The po-wibility of such eommunieatioii wnn long denied ; 
but many weU-authenticaled ca8C« in which Hm dcplomblo accident hna 
occurred hare now beou puhUshcd. luid thu eriJimco in it« favour l« ooiu- 

Jfariid Analemj/. — Infaotile sjj>hilis, like the othor diathetic 




of nhildhooil, nuj aSbet tho timoM wry widely. Tho pathologicAl «1une- 
(cre uiu> bo dirided ioto tliroeclawoa, acouriliu*; us to wlioUier Ui« pu-t aflect- 
ed U a'luuooiu membrBne, a solid organ, or a jMrt or the bouy friuue-tvork. 

Tli« uituvtis wierittmirH' may be tlie tieat or aitatrh, of mucous pat^hcft, 
or of ulc«rs. All tbeue taay be Hoeu on tlie iuaido of Uie oliecktt imd lipe, 
tliii faucus imtl euiuftiuicft the sniiill intestiitc ; obo upou Uie Ijuyox. Uie 
tracUett, and even tin? bruuclii 

TL« iti»ide of tbe mouth is a common seat for eroBiona and mucous 
piitc-Ii('8. Tlic> du not sprend down the ^dlet, Aci-onliu^ to Dr. Jobu 
ftlucl:«iixi« ; uor Are t1ii>v to \to Meu oa th« posterior wul) of tbe pliarjiix. 
In rare iostAQces nri^hilitic alceratioii is (oand in iho graaH iiit«atiii&. I 
ODoe saw a little boy — tour yeata of age — the subject of obstiaate diar- 
rlicea, iuwfaom tL« evaouationx bad aU Uia cbanictcni usnnlly found in cases 
of iiiccmtion of tbe bowels. His fatbor hail Itatl Kvpiiili», and his nioth<>r 
iu ber nest confinatncat ^vo birth to a diHtiactly H\-pIuliti[: i-hiJd, and Imd 
oftenvarda aeveml uiiHcaningea Tbe caoe renistetl all ordinary remedies, 
but WDA eTentiially ciinKl by tho oontinQed applioalion of a mercurial niut- 
niciit bo thf' ftlxlonicn. 

Mucoiiti piitchi-if iiQiI ulvi-m uitiv be twen on tbe gtottiii and einglotti& 
Tbe vocal cunlH may be dv^trovvd by ulvvratiou or may be th« seat of 
warty p-owtha A case in elaawbere relstt^d (see page 417) iu which ob- 
struction of tbe liuynx by warty feTowthu occiin-ed iu a cbUd who had n 
putt sypbililir lu«tun', but iu whom no other coualitutional Icwou cotdd 
W diM^oiC'r^d. Soiueliuiex (Treat thickoutug ia iiotived iti the muLXiiut 
membrane of the glottia Thus, in o ca»e reported by Erves — a ^philitic 
child nged tbree mid n lialf yeani — a laryngoscopic examiuatiao diowed 
that the rpi^'lnttiK v;na thickened to three or four timea itn natural ribo ; 
tlip an,'-(.pi(»lotti<lMiii onnlH were tliickened and pale rwJ ; the left vocal 
curd was more than tvrire on thick tm thv right, luiil huIgiHl out at ita cd;^ 
towards its fellow. Tlit Bynipttjuis were aphoniu, iind frequent couTulsive 
fits of coughing with Hulfocativo. iittackB, The child was treated with mer- 
curial iuuuctiouo, aud WHS well iu two mootha and a half. Aocordiiig to 
Dr. T. Uiirlow. tbe hirjiii, rvtii a(t«r recowry, i» left very BeiiaitiTe and 
Huxceptiljle lo freiih cuturrb. Th)^ uiueoua membrouc of th« trachea and 
bronchi may be aflectetl in a siiuilar way. There may be catarrh, or mu- 
cous pntvheB, or sliallow ulc-ers ; but Uieae leaioua are less common here 
than at the upper part of the respiratory paasage. In rare cases the ul- 
eeration may be exteuHive. Thim, liVoromcbin found id a child of fourteeu 
moiitliH old tdcertLtioii of tlie lower part of tlie tracheti, and u similar letiiou 
of the right hrnnrhua which extended as far downwaida aa the next dl. 
Tiflion of tbtt air-tubo. 

In tolid orffan* ^-philitio Ic-aous aRsiiine the form of libroid growtbi^ 
which may be either diiTused or cii-cuuiscribi-d. Whatt-ver organ b« af- 
fected, tbe natixre of tlie lesion is tJie same. Tbere in hywrphuiia of the 
connective tiR-tue of the jHirt. This growa, thickens, and tmally eontmcta, 
BO that the proper pHreucbytna of tbe or^(au is oblitciattid luiil replaced by 
a solid fibroid material. Wheu the leaion in drcumacribed it is called 
"gumma." Tliis hUR cwientinlly the Rtune atructure as the diflused form, 
but lends to Aoftcii ill the centre by a process of fatty degeDenttioD. 

DiffuHod fibroid change u m-ch iu the lungs, liver, spleen, and pancreas. 
Crunimata have been found iu the ttuiue orgaux ; also in tbe heart and tRil>- 
eutiiucoiid tissue. Occasionallv they ai-e found also in the tongue and »oft 
palate, but not in inf»iit«. Thu ia a kter a^mplam and aelJom occurs be- 
fore the end of thu sixlh year. 



In a lung the sent of iliffuncd filimid change, Uie pait is HoHd and gray 
m colour, mtli a smooth i>iiining ttecLiou tmvei-aed hy line llbrotw Uucb. It 
» TCiy iliouM) and tough. Uodor tlio iiiicroiti^ojK- Uio lUrookr widls lU'e aeon 
to be iufiltnittcl with rvuntl CL-Uts sj^iudlb ouUs, uuil tibrouii tieaue. The 
roond and spindle celln dcvtlup into Sln-ouii tissue, whicli thickens the 
eeptaanil compresses the alv<?(ili. Thero is also fn^o ]>i'n(hictioij of upw 
TCutiU. *o tluit tliit U6vf {!L\>wtb is vvrjt' viwciilar. TLi- area of lung thus 
kfleciod Tnrics. Umulty thu diitcaao oxtoudti uvt- r a jutrt of a lolie. or even 
a whole loba BeHJdes the dift'uHed form, I'ummatn are acen BoiKetiineii in 
the luiign. 'rh4>s6 nre muu<lc<I wfrll-ddineil miutscs, few in number, umally 
of tJie taxiO of a nut, aud jcUowi^'Wliitv or ^rii^' iu coloiu'. Thvj arc lirui 
at llw circumferuut*. but yet softvr iii tjie ceulrw. and the iiit«nur aay be 
tnduced by fatly d&^uemttou to a. puriform matter. MicroHcopic ex- 
auisation sUow-tt the lilreobir walb to oo tutilti-ateil at the cii-cuiufereuc-e 
of tti« tutnoiir with niicl«ated cvlltn, while nearer Uie centre round or oval 
oatis aro wen in a liiivlv rclicidAUnl tiHHiie. TLoho two foriiiK of llie tuune 
Utiau are seldom Hef u, oxccpt iu doud-boni or vei->' yunug infants, 

The liver may lifi afTectt^il, and, accordirij; to Dr. I'wrot, is most fre- 
quently found disGRKnd in iiifaot« who din six wi-cks aftf'r biilh. The or- 
gan is «alArged and lianlenwl, aod inny ha thr siuit of n Krli-roiiiis dilTUMsd, 
aa in the tiugsi, or, laum raroly, of the L-iri'umHvrihi-d form. According to 
Ouhler, wbo first drew atU-utiou to tlux canditioii, the urgan in the dtf- 
lustfd fibroid change is hniertrophied, globular, tiard, unci bliistic, and its 
edges lU'o rouudur thau iu LvoltL It cxeakn ou tsL-ctiou, luxd tbv cut kiu- 
lace in pinkiali-tvhitu or yclluw, mid aliuwit layvnt of muiuJL whitt*. upitquc 
grainn ou a yellowish uui/<»riu grouniL The capillary vessel* are olilitcr- 
al«4l, aud the nilibre of the burger ressels in iucreased. These clutugei are 
due to tli«) tl«velopmeub of new libro-plaHtic tistnie wliiirh cotuprenHcs tlio 
hepntic cells, obliterate* the vwwelM, and checks or prevents secretion of 
bile. Guiiiiittita nmy bt> couibiueil with the pn-iNiiuu;:;, and ar« rteuu at) 
^■irtTumstrribed iiodidtrH ondirdiled in healthy tiasue. Themuaseaare brij^ht 
yellow, aiid preiicul under tlio iiiinnsaiiw tliR usual round or oval cells. 
^bara is oomoionly moiA or ll^»i.^ w>fti>iiiug in tlio nt'otrn, wliilc at tlte cir- 
ContfortDee the noriu.-il )iop»tic vt-iU, hctvaon whicli the intiltratiou is nd- 
Tanctug, bonomo hypcrtntphieil. 

The Kpleen ia often enlargeil, anti, according to Dr. Oee. if the enliu^e- 
Kiint is great tbe ciiiM will probn)>]y die. Dr. (.tee considerB the decree 
of uuLuvcmf »t to be un indci of the tu'verity of the umchcxia. U the vuild 
itDprore» the size of tlic ^[ilctiD does not dimiiiii^U lut the otbe^r symptoms 
di^3pear, but continues uuiUtwred — often for yeaiB. In tlio spleen, tw iu 
the other solid organs, the disease consists principally of a dimieed int«r- 
atitiol h^iierplosia. 

Th« henrt aud luufn tnay lie aUo affected. Guniniata have been found 
in thu former orffan, atid Dr. CouiJnnd has doscriboil a iqjociineii in wliicli 
Uie niiiaculur wnlU were Uuckeueii and faardonod, and showed luiJer the 
[inicnwoope an almost uiiivei'aal lafiltnition of Hiuall round cells amoutptt 
'Uis muwntlar tlhrca In tlw mane eoite the kidncvM, although normal to 
the eye. were ih-cu to bo undergoing eiuulor ch;ui)fcH, und their tFubstaiice 
was nnbiitumlly finn- # 

The thi,-nius gland in sehloni diseased Sometimes cullectioiii* of innt- 
1 t«r an> found acattei-e'l tlirou^'h itn interior, but it is not clear tluit tluute 
\an the i-ousequeucu of the Hvphililic taiiiL 

The Kuprarvnal bodies art* xuid by VirL:how to be frequently the Mat 
of a fatty degeneration. Hiiber htt» JoBcribed « couditioQ iu which theue 

Jieue ^H 



lioilics are Inxge, (^rayiBh on Uie cmtoicl^', traimhirent, «Dtl Oiiok, with na- 
iiHtriJUit wliito, irrR^piliir spottt ilispersed Uirougb tlioir muImIadco. 

Th« bon«» ore ottC'ii tlie B««t of profonnd stnictuml (liseaw. Our 
knowle<1ce of the boiH- iltHoaw nliich occors na a contimmeiice of inberitf^I 
sjl'liiliit in only of re<Tent oriyin. Dr. O. W'egner was tJie linrt to <1e«"rilj» 
tbeeo l^^MinnK, nm) nttnlmti^ tlinm In Uii<iir tiiie caitse, iu IKTO. Slore rv- 
contlr Dm. Parrot atiil Coruil lisro kbuurv<l at tUo aonio sobiecl. Dr. 
Tnylor, of New Vork, who has coUecleil mmiy fn»e« of hiso«-a lum lUinlytMHl 
thoHc of others, gives ii grajihic account uf thBue RffeL-tiooH in liiti well- 
known Toluuie. 

DtsciMu uf tilt- osnt^ous sii'sUtm is a far from uoGonimon lodoo. Accord- 
ing to Dr. Abelin, of Stockholm, it ig fouiul in t«n per ewit of the casen. 
The Itonea eiiperiflUy ufltctwl are tht kmg boiieH of the Umba ; next come 
tlie bones v( tJit* itkiill. the rihii, the tk-^pulHi, ami the ihac bones. lo the 
long bonea thi-rc arc two chief varielicM- One beguis with tli« perio«teum 
— |)eriOBteogeu<«i8 : the othor ia u<f1 oiiriuoctot) with tbo p«rioet«uui. but 
ifl confined to the ossifyiug liuc of lh<.' tUaphyeit — osU-ochondritia 

PerioftteogeiieHia begins aa a prriostitia. I*armt tliviileH it into two 
foniiN : tbe oHt<-oid and the spongioid or rachitic. The foiiner may occur 
from the cftrlieat period of life ; the latter ia rarely lieen iu infants of )«ai ■ 
tlum nix uiouthu old. 

In the osteoid form wo find one or more laytr* of a new growth which 
i8 eoMiposed of inlerlainng traheeulM? lying peri>eH(hciilarly to the asis of 
the »linft. Tbe perioateuni ii? thickened and adh^r^-nt to Uie*g»>wth, aud 
tbe Iatt<-r bns a chMky npiK'nriuice fTOiii copious iiiUItratkni with ralciueous 
sallK. CL>uM>i]U(!iitly it in whiter rind niorr (nahlti ibau tbu )>t>iie beneath, 
and tlie line of junction ia well dclincd. The osteoid material is f<>uu<l on 
tlie abafta of the long hoiiea and on Uie <i-a!iial boiien. In llie latter situ* 
atiou it may reach «ii iiieJi or more in thtfrkneai*. By iIm" ]nic]'08(.'x>p« w«,l 
find dilferem'es in utnicttiro from true bou«. There ant no bou« oor>1 
puaclea regularly iliKnottod round tbf Havcnslan nioala ; inHtead corpusdes j 
— three-aided or [lolygonni, resembUiig tlic atellate corpHwlefi of ronnee- 
tive tissue — ^notrtoninse by tlieir proeeHROH nitli the oellnof tlic poriosteuiii , 
witl) corpuBolca in the nicdnllary fipaeea, and with one anotb<>r. 

In the Hpongioi<l form, which ia uot xecu in chililreu uoder six months 
of age, a new fibroid tissue, pearly gray or yellowish in colour, is formed 
betveen the poriuateum and the bone. It is more ^'shciiIbi- than nomml 

The oeteuid and spongy growths are often combiued. If the new ma- 
terial uouKtat uf several invent, aonie nisy bo more trabecular, oLlient more 
Hpimj,'r in structuie — the chalky layer being ueiirer the bone, the fibroid 
iiiiiiiedialely beneatli the periosteum. \S'hile thia proreas is going on 
nroitud it, the ahnft of tlie Itoiie may h« unidtercd. Tliis La usually the 
case in very young babies, In older cbiMrpn the wdcaiwiUB matter of tbo 
shaft may become absorbed, and the tissue be separated into layers by 
Uie formatioD of furrowB filled nitli medulla. Tlie bnne aa a cnnsHiueDC* 
IvcfwnM light, pomua, nn<l brittle. The ends of the bonea ore thiciencd, 
jjiirtly by the periontcopeuftic growth, partly by gntnulntioDB thrown out 
from the spongioid tissue of the nhafl. 

Ost<foehoniiritis itjipeant to eonsiitt in a suppurative osfitia nJTevtiag the 
cinphyeeal ciid of the bone. The layer of oartilage prepjiring for osaifica- 
iioii bccomfs thiekcuetl to ibrcn; or four timcH itn uatund width, and gets 
t nuis^iurent ami M>ft. Tliin increa»H> iu width is due to excessive prolifera- 
tion of the cortUnge cells, which assume much the ehnpe ami size of the 



ronnd ft^O'UlA'ion cMIb of 8\-pIiiIitic gummaia. At the sfune time the 
interccUalor mibstonce is ilimitiiHliC'd. The rarliioKR wbit-lt i« at^timlly 
undergoiQg osKifiuatimi is tliickeited. ami shows on twotion a liroiul wavy 
line. Hy Uie micro8co]>« the oHlcobliistH ai\^ foiiiK) to he replactd more Of 
lew ooiDplet«ly br 8iauU ^imuUtiuD ccIIm or iipiuiUe-Hltaptxl elements. 
After a tunc deatructiru chaugeK act in ia the Iwrny tiiisua Dr. Parrot de- 
Bctibee a " gelutinifonn softening," in wliich the iHine in rcplncod bynsoft, 
mtiicr tr&Q3par6Dt materinl of a ycUovrisli or bruwiiiBh colour. Aftcir 
tltsitli. wlivLi tlio boiic is diy, u cimty is left. Tbu ctiiiccUoiiH Htnicture ia 
xluo in&Itrated with punileut walerj' Huid, so ibat the lamellHs djaappear 
and leave a fibro-vaaeular netirflrk tilled with the aanie fluid. According 
to Wefiner, a cb«racteri«tii' fwitui-e of thin oR»ff}im ditte&se in Ww protru- 
aon of bundta* of lllii-oiiit titwiie tdujitj llio coiinte of the blu'xj-VL'SKelit. 
Those bundUn piiwi tbroiiKh iho eartilaK«) the caliufyiag hiyer, ar<l tbo 
processM of spon^'y Ixino, aiid penetrate deeply into the caDccUoiiH tiH^tue 
of the fdiait 

A:* ft oonsequonc© of this Idsiou the opiphy»08 with the ossif^-ing layer 
auiy BOporate imm the shnft of the boue. Suppumtion is then net up, tax 
nhsccaa forms, and the pus cHcaiies into the surronnding Ubhub by peiietiitt- 
ing' the periosteuia. The joint itoelf Ih not involved an a rule ; bnt Dr. 
Leefi has reported a oaae in which the left elbow-joint and botli knc«-joii)t4 
became &Uea with pitt. 

Penc«t«o;reuesL8 is nior« common thou osteochondritis. It attacks par> 
•ticularly the huiueruH and the tihiu ; and gives riae to aymptoms, reoog* 
3used during life, nLicb will be aft«nv&tilu described. 

.All osflpiiin lesion, due prolrftbl;^' to chitugea similar in character to 
tlxMO do«cribod above, nod ciuled diu'tvhtiu, may attiick the bou&u of the 
hjuiilM iind feet. Dr. Tnylor, of New iork, has roiitributed much to our 
tiwjwiedgc of this nfTei-li'i.i. According to thia nutbov, the diiieaae begins 
either in the flbrtjus tiKsttu surrouiidiug a joint or in the peiriotiteunt. In 
ihi- tir«1 form slight ciilai-gcincnt is Been of onn or moro toes or fingerit — 
cither of the whole length, us occuns in the toes, or of yue or njoro phn- 
'3imges, aa ut seen in the rase of the fingers. The procetM ih hIow and is 
wwompanied by little or no pain, ollJiQugh tlie Dwelling interfereH with the 
pby of the joint The accoud fonu ia moat frequently soon in the lingers. 
One or more of the phnliuigvs bt-comea evenly rounded or fusiform. 
'When the firat phahitix U attHoked, it; utnially assumes Uie shape of an 
aoorn. The metacarpal and metatarsal bones may be alao affected in the 
flame way. In all ciweH, ivt n nili-. the k-ndentiy is to resolution. Still, 
aomeiiiuett, if the tiiliU'gi<iiient isgrt-at, tlie piuL is L-X|>08ed to nccidenlal 
injury. The skin then becomes swollen, red, and tense; uloi'mt«e or ia 
ineisod, and iliacharges a soft, <.-heetty detritus mixed witli piu*. Limited 
necTOttia may follow and lead to *horl«-niug of the finger. Diictylitis ia 
mmally sorn in very young children, but it may bn h IhUt syiiiptmn. Tlie 
tiuralwr of tiugcra elected raries. Dr. Taylor mentions n cniw in which 
all the phalanges of l>ofch haudn were involved. 

The bones of the skull may be alTeeted by the two forma of disease 
■which atttwk tJio long bones. OeUtinifomi aofU-ning is comparatively 
mrc, but ia aomelimes found in Yury young mfantK. It begins benoftth the 
paricianiiun but does not [Nfnetrate deeply into the bone, so that it rarely 
rea<!beB the dura matr-r. .Uter deatli Uie bone has a vroi-ni-eatcn appeiu^ 
ance. This form cimuol be lUaynosed daring life. The osteoid growtlw 
are only foimd in older childrvu. .At lirst they always occupy the 8<u»o 
situatiou, viz., the fruutul uud piu-ietal bones Kurrouoding tke &ut«rior foo* 






iiii^llo. Rometimex they are also Men in tlie t«mponil bonw. but arijj 
novpr foiinil, itiiU'xs Uie diBWSo bo exct^pticiuallj- severe, in the orbital!' 
j>lnt«iit or liiv orcipital bono. Aa tliey grow tliejr produce a very charartei> 
i»lif tl(?ruriuit.v of t!ie Hku]l. Tlie fontaiielle ronies to b« siiiTOtiiidpd by 
four eleval ioiiH, nOiich nre sepamtod }>y two fiiiTOws iril<>rwoliii({ oao fuiotlier 
ill tiio foiTO of Q ctom — t-lio on* traiisvorsc, the other Aat*r>>-pOBt*rior. 
TiiL-nc ivstoopliytcs itn> usiiollj spoiipi- and poroQs, but they may hccomo 
liiird ».iut tiiiioDth like normal bofie tistnie. Tbey aotDetimei readi an ioch 
and a quarter in Ibioloiciu*. 

lu addition lu tbv aliovc purniy sj-pbUitic dianf^M, loco] ihinniDg of Qio 
bone, ciill«d crani'Mlabes. is often found. This i-oudition. which is a ihin- 
ninc or evea perforation in certain spots of tlie cnuiinl bones, was until 
lately culUi<lcr«d to be excliuuvL-Iy a ^yiuptom of rickets. Il is du« to di- 
rect preisKtird upon the bones of the Mkiill by ILl* brain vritbin iukI tlio,' 
pillow without, and iu found eapeiniLlly in the occipital baue. It may be* 
prfiHont in riokelB where no trace of aj-philia can be disoorered, but U most 
counion in vanes where there Li adialinct BjfpbiJilic laint' 

It ia iliflleiilt to nay with rertairity at what age a child Ireoomes liable to 
sypliilittc diJWiiiK! of bone GeLitinifonn soflcninf* and o«t«ochoDdntiB 
geurrally occur ciuiy, bcpnning before the sixth month, and it ia probal 
tliat they may even W preaent in intra-uterine life. Dr. Taylor has mc 
frBquently Keen ostt'ochondrilia about nix weekn after birth. The cbang 
in the onuiiol bum.-!t m-viu to bo latvr H^Tuptouu, and to occur most con^] 
moldy iAUt the »L-coud 3'eiir. In itouie cbhck rcporit^d by I>nt- Barloi* aud.^ 
Le«H the »{!(■« of Ihu irluldreu were between two and three years. Bond 
changes luiually occur in the most severe cnHea, although it ia said that 
tliey are sometbnes the only svniptom of the diM'aM:-. If the patient re-^ 
coTer^, all tmceit of the morbid growth may dlHuppenr, but it is not 
to find ciirvaturea or twists left sa evidence of the cachexia which haa 
pafi««d away. 

.S"ym/)fot)i«. — The firat manifestation of the coDstitatJoanl taint may op- 
cur early or Intt^, noeonlin^ to the degree to wliieb tLARyatem isafleeU-d by 
th« xiniH. Whon th6 nyidiiHtie iKiisii>n in vcrj' active, the di«uec may first 
tibnw il«c!f dimuK intra-utcrine life. The fstim then diea and ia bom dead 
before the proper time. Sjiihilis ia thus a common cauae of mii*rarria^e ; 
and in all cjiHrii where premature lalxiur ia found to have occurred repeiit- 
etUy. wc tdiould not fad to mukv inquiry Du to tltc pre>')Oua heoltb of the 
parcuta. If esaiuinutiou of the abortod fcKtun be made, the bouos iiad in- 
ternal organs exhibit ugus of being profoundly atTected by the i^-pbililio 

lu A less active alate of the ^'inia the child, ultbougU diBcased. may lie 
born alive. Ufl in then much eiiDtciatiil and looks shrivelled. His body ia 
covered with an eruption of pouiphiguB whirh extends even to the paljua of 
the handa and soles of tbe feet. He t»rtuftU-8 anti has a hoarse ary. If, aa 
(feuenilly happens, the int«rmU or*i::inM iti-e e^U-nsively diaewted, the cbild 
dioa. If uo disease of the intonial iir>.'a]is be present, the child may tinffcr j 
for a loneei" time, but he ^nei-ally diet* in the er^l. It ia only in rct^' raraj 
casea that he stru^glet> on and eventually recoven. 1 

Usually when a Byphilitio child in bom oUvo, he has at first a healtbyl 

' Out rrf on* hundred «ium> of rrmnio-tabi-R colteotpd br T>r>. Barlov and Lm*. 
fortT-st-ven there wm Mtisfoctory proof of njpliilia, tn tnnj llt«re was uore or 
eri'ltrnce of tlic diseaae, ualjr Lu Iwvlre tim Uivtv no iiMlkauoii,*)^ VPhUlB to b« 


Mpeapmcc. Aft«r n time — oft«n b«twMQ two Anil ax w««ks, rarely after 
tbme months — the firet i)iinu> of (be dineiuie appear. Before tliia. liowerer, 
tlie cliilil in many caiu>s liua ati uiiL«nltliy look, although it is difficult to 
saj in viuA tliis unheolUiiuoHK coUKiHtK. There ii* oft4>ii gi-nat rfii«tl<>eHDcm ; 
aoA the infaot muy ftleep biidly ut uigbt. »uiiii'timc8 bn.-ultitif; out iuto 
punxyiRiia of violent crj-ing. wliich are a Bouroj of jirent perplexity an<l dis- 
tFMH to hiR Attendants. It Hcemn probuble that thiR fi;,-niptom is due to 
noctumnl pniiut Ui tlie boucs, «ii(-b as often afiect a^lulht bcforo the outbreak 
of roDstitutioDiiI Bvuiptumx. Tliu tilt-vpIc-iamirHH noon c(.-aM.-!i under the iii- 
lluenee of sjjeriJic treatment. SoumUmeB tJie outbreak of tlie general fi^-nip> 
toms is <let«nmtie<l by a febrile dieeiU'e, ouch &a x-aocination or one of the 
exaatbt-matd. 'Hi tin, it in not \eT\ rare to aee the rnnb of nicaales subside 
leaving ibt^ «yphilitt<; fruption in iti« plfw«L 

SnufHin*; lh out' of tlio oiirlkst symptoms. It should alw»>-u Im> iuquin'Jd 
(or, AA while the child is brcatbinf; through the mouth it isnot noticed, and 
th« motber attribiitiiij^ the Hvinplora to a eold may not- think it dfiserving 
of metitioD. Tli*' RiiiifHiiij,' is most fvidfiut when tlie ehiUI take:* Ihn lirftii.<«^ 
HH'I his maunor of doinj; ho is* very <!hiimct<'nRtiR. Vjioii brc&tii in dmwii 
with difficulty tbrou;;;!! the noatriLt. anil if the ubHtnu'tiun in t^reiit nrK]>im- 
tion hnn to he suHpended while the bnba bucIch. Consequently, he nm only 
dxftw the milk by aliort snatcbea After even,' two or three inouthfuls 
ba iM forcnl to dettiftt, and can be men Ij'ing witL the nipple in Iub half ojteu 
mouth HO AH to reu6w his supply of air Iwfore he be^^iug n^aiu. A discharge 
ftfMD the uowtrils soou aj^ait;. Tliii^ i« nt lirttt wiit«ry. but. hoou bBcoiutiH 
thicker auJ forms crusts which block up the uAsal op«niiig8. Little ukera- 
tioDS and cracks are (renerally wen alwmt the nostiiln ami upper lip, due 
either to mucous patchoRor to Kcalding by thr* irritatint; Koerptioo from tbo 
Dose. In bad <viA('>t ulcomtion of the Sclinci<li>ri.i]i tn^THbrano raaj* tako 
place, and the setitum ia »oniettuic8 perforated. Occnsionally, ncnroHis of 
tlm niual bonea U)tlov>-<i, and frnfrmenta of (he boneK may be found in the 
dri«d diMiltiirgo. Tlie lion^a limy be also loosened ho that tlie bridge of the 
soeo id flattened luid suiks down. 

Another early ityiuptom it* Ihti rash. Thiti aiipcant. as a rule, shortly 
sftor the beginning of the eoryza. It is Keen uh lIultcintHl, itli^litly elevated 
«pots, of a maty re4 or coppery colour, eeattered ov*r the perinieura, upon 
tile ((ftnitlds, and around tlie anun. HomeHraea it begiiia aa a unifonu, dingy 
re<l blush eoveriiig the Wily, the j^riiitvmn, and the butbockx. It soou 
oaanmfis tlie tint of tbb luan of bam ; \\» edi*e in distinctly circtiinsoribod, 
and at the nircuRiference isolated spota are »eeu of the itame colour. The 
eruption is not confined to the lower part of the body. It is often seen in 
ihu fnlda of the jointit, particularly of tlie aniipilK, nJong thn Kide!4 of tlio 
neck, ami over the obin. Otlirr variotios of <>niption are also Mien. Kcthj- 
matoiis and tubcrculur aiKtta turu not uncommon, and mucoua piktrhiit and 
oloermtionR are conirtantly preBent on the skin. The ectliymatouH pustulea 
are loct with in tho more weiikly cliildren. 'Iliey «re generally covered with 
a thiekitcab, uuder whicli tlif nkiii may ulci-nitv into dft-p, nharply cut norea. 
Uuooua patf beti lie at tlie outluti> of the various piiKsiigeK opening on to tb» 
tmrface of tlie body, and in other platreu where the mkin ia i>Bpecially deliente 
lutd moist. Tlim (liey ni-e aeeti aroiuid tli'- anua, and in a girl round tlie 
rulra : atao about LhecoTiiiiiiH.niires of tbu lips, and between tbeflngeraand 
toee, Tbey are round or uvnl jmtcbeti, itliglitly elorated. The surface is of 
a grayish colour and ia motstenod by constADt secretion. On a mueoua 
nietnhraQe they quickly Ijeconie conrertwl info nhallow nlcera. Ulrcmtiona 
nnd cradu invade the angles of the moutb and aUe of the nose. Tbey aro 




linciir and lenvp b^fainil tiiPin linear «iontriee<B whrn they beoL Tbfl skin 
iUieir of a H^iiliilititi clitlil praaenta a rcnr choractemtic appoanuicf'. Id 
mveee case* it is dij. inebstic, tatil nrinklnl in Ickmp tokh. The conip\ex- 
ion in ydtowisl), ojid bns heca oomjximi to ncnV cAftVAU-lait 'Iliis tiut is 
unequally dtethbuted, beiag most marked on tbt- prominent ]>flrt«, as the 
nose, cbeekf), forelieiut and cliin. Tlie general colnitr of the skin may be 
muddy ; but ID eliildrcn whosurrireit peuerally Iwcomes singularlv blood- 
Iws, 4nd rcinAins pnlo long nft«r otjior tn'mptom» hnve dii(npp«ar<<d. 

Tile litur nud cvebruvni wruietiuiet) fall uuL 'XTic unils uaaj also be 
affeetRd. Inlitrnmation and auppuratiou occur ia the niaUix, so thai tlie 
niilrilion of tlie noil becomeft iiii{>aired and tb» nail gets dry and is ea«t 

Tho cry of the infant is n uolicenblc symptom. It is lioatsc* and high- 
pitclied from laryngeal catarrli or cxIeuKion of ttie niuooiis ]>a1clies to tbe 
luryax. OccasionaUy tbe hoarseness ia accompanied bv attacks of lfti;\n- 
giamua stridultw. In almost erery case tlie niwatinihoa of llie eraiiial 
boDeM in dulnyod and the fontanp.lle im n-idnly oi>en ; but the gi'iiwlh and 
development of tho tooth arc not interfennl with, for Ibo lootli are out 
early, an a rule, and with htUo inconvomcnco to the child. Cisnio-tabea 
ia present in tlie large majority of tnacji, and the posterior cervical glands 
uro often enlarged. 

Tho bone mneMtt pj-enenta many very dumwteruitic Bymptoms. Tbo 
loHR IjoncB should be cxnmintd for Bteiis of enlar^enitut, cspcdally tho 
humeruH. the femur nud tibiiL If m pJace the finger and thumb on tbe 
anterior and jwstenor aspect of the hiimenia at. the upi>er part, and carry 
the liand downwaiilrt aloug the shad, we ehnll often notice that tlic bono 
become)* tliickeiieil at the lower eml, and that the tliickening ia gteatert 
at the point of jtnu-tiuii of tbo idinft with the epiphytds. In tbe tibia the 
thickt'uint' can be often detected on tho inner auirfaco, in tbe femur on 
the oiit«r and inner aspects of the BhafL Beeidcn theae, lliere may be 
Ix^ttding of the rilia and thickening of tlie nulius and ulna aboto tho wrist. 
Tlie 0)stt>0]»liyteH on the orauial Ijonrs have ahvady l>eeii licBi-rilnwl. 

^^'hen Hiippumtioii takes pln<^e outtide the joint, especinlly if there W 
fracture of the neck of the bone, we liiid pefuliar ttj-mptonifi. Tlie rhild 
nppenn an if pandy/etL His arms Ue prouati>d by tbe aides of hia IxKly ; 
lu8 lepj are stretched out straight in the cot ; and when the patient ia 
liftod up, they hnug loose, like tlie l«g» of a doll, BU'nnug from side to 
aide. Crepitation can ftouiettmea be deteot«d between the Hh&fl and Uin 
sepamted eptph^'Ki;4 ; and if an abscess forms, the joint, wliieb bad been 
tender before, lieoonies ))eut and stiff and exquisitely painful. Parrot bns 
called this condition ■•sj-philitic pfteudo-jwalyais." 

A form of real paralysis has bMD ORcaaionally xeen affecting tlie branches 
of the brachial plexufl, and causing more or hsi complete loaa of i>ower in 
tlie anna. In two caaen. deHcribed by Dr. Hcuoi-h, voluntaiy movement 
wax iiltiioMt enitipletely lout in the iip|ter extremitieK, tbe flexor muacIeA of 
the fingers alone nrttaining a alight Iiyk'*' of eontraetility. There were other 
signs of H\-phili8. and the pfLnUysin disappeared under the influence of 
mercury. In Rome cases a peculiar tiviKling of the bead badm-OKU hnti 
been noticed when tlie child in iiloc^ed in a sitting position. 

The dcgrvo to which the chihl is afTucted iu ciuw-s of ttdieritetl sypliilis 
varies — partly according to the %inilcnee of the poistHi, and partly, alao, 
aeeording to tbe general stivngth of the infant. In rare casett, where tTrioB 
tan bom of parents ciifTcring from thia disease, the two children may be 
affected \-er7' uiie(|iiiil]^ . An iutKtauoo uf thia cotni- under my omi notice. 


The ehildron were thpr>p nionthR old. One wns miioh cinncifttod, with & 
(thrivL<il«il, ixirrli tufitt'likt- nkiii. covurcd uitli pL-!ii]phi<^& iHto suulHi^d 
attd friwl liiji>r!«.'l_v. The olLer wiis ii liealtli_v-li->olcing cliilJ, fat aud strong, 
vith m giwU eoiiiplexioi!, Shu HuulUed mid abawed on lier butt^cka tdgtm 
of r»oeut erupUou ; but was uever Uiougbt nuficieutly ill to require uitKlical 

lu practice we see ever>' degree «( iiiteiiaily of the Bvphililip pacliexin. 
In ooe CAB«, like tUe lieaJtbier tn-iu jiist meutioaed, the iufoul ma;y^ 
pluiDp Aiid stroii^'-lookiii}^. witli few HvtupIomH iiud tbosf triJlin<; in chur- 
ficter. In aiioIIrt tbe cliild in wizoiieil nud wasted, with n wiiulded, 
metftstic, bloti^lir nkin. He is peevish imd restlese, cryioQ hoarsely and 
whicoperin^' iiliiit>st< t-ooittanU;. He in alway8 hiiiijrry, for tbe state of bia 
toouth an^l iinuil piLAniageK omr» n oontinimt iiupmliment to his drawing 
Buffieient nourish meat from Ibv bnuiKt. Ho ^(r1i4 tvcAker ancl weaker — 
partly from dtseose. portly from wad of food. Vomititig and diarrhtsn 
perhfUM come on, oud liin nii(<emh1e httJe life soon drawn to n cIohc. 

Wbea the iii&iiit Rur\ivfjt, ho mny wRin quite to ihrxiw off all traoea of 
his UlnMH, and ptrow* up n stroufj hcAltliy cbild. But uBHiLlly, when the 
symptoiDD h»To bocu Hcvcre, more or least pormonent impreiisiou ta pro- 
tlaced upon tbe «)-itLeDi. The body may be stunted in ginn-lh ; the com- 
plexion earthj or unhealthy- looking ; Uie liiiir tliin and brittle. The brain 
miiT be a]»o more or Iukm aQucted, luid i-pilcpsy, dclicivut memory, ]y>iia of 
perci-ptive power, aud even gradually advauciug imbecility are enuniemtftd 
as (ruiisequuDveH of the diaeiu^e. 

ihiopfct. —In i-are cases the s^'mptoms of inherited syphilis are said to 
be deUyefl until the HeTenth, ninth, tentli years, nr even latfr. Moat of 
IheM oases aro no doubt instnnees of relapse of the dieaiwo, tbe Ngrmptomst 
which occurred duHiig iufnncy hnving been slight and tnuisient Tho 
relniMte shown itself in cxipjicn- eruptions on tho ^iu with di«rhm-gc-» from 
the nose, earn. et<:. The skiii often idferates, and the na»al hones may be 
tlcatniyed l>y gummy oiilititt so tlifit the bri<lge of the nose ia depressed. 
Tbv Bpong)' boucft uud hiird palntc may ulcenitu nwuy, oud Ibv virlum and 
pilhtra of tbe fauoeM may lie destroyed so jus to throw the noso and mouth 
into one cavity. The eyes may be affected with inleratitiiU koratilia ; the 
permaoent incisor teeth' may bo notched and dwarfed ; and deafness may 
ooour. DoafneBS vt tho cumtoqut^uoe, as a rule, of soma morbid coiulition 
of tbe auditorv nerve. It is seldom ftccompuvied by any ditteas? i>f iJie 
outer or middle eior, for there is linuitus, aud the patient caunot hear n 
tunmg'fork pl^i<;ed on tlie heiul. It is mnst coiuinoii between thohftb aud 
fifteenth yfiars, and ran seldom be iroprovenl by treatment. 

Epilepsy has been nioiitionod as somctimoH occiiri-iiig in ajphilitio chil- 
dren. It IS Ufluallvono oftbe latcrfn'mptomu, aadmay osiut, as wax xtvn in 
one of Dr. Ilughiingx Jackson's riwes, without any siyii of orKunii: diwaBii 
being detected in tlie brain after denth. Syphilitie children somelimee 
Hie firom a baxic mcniiiffitis with symptoms similar to those produeetl by 
tho tubercular form of tlie diseaflc. Thpy may also siimimh to ar^re- 
bral hiemorrhage. Dr. Itarlnw ba<* dewribod a diflfiised thickening with 
opacity of the arterial eoats iti tbe brain nji somettmes occiin'ing in easesof 
inheritcxl Ky]>hiliH. This may leiwl to thromboua of veesoU or rupture of 
tba art«ry with fatal luciuarrbajfe. 

Ijuilj, in many eliildren who have sufficed from the hereditary form 
of the disease we may liml amyloid dcgoueratiou of internal organs, espe- 
cjally of tlie Hvit. tbu sjtk-vii. and Lhi- kiducys. 

Diagnosis. — Vi'hea the symptomii are vrall marked tbe nature of tbo 






Ldiamse enn soitoaIv It^ inifttAkon. Thn liitlc, old-looking fact, with its 
iduskjr oonipU-xiuii, iU dtMiiivJ lipn iiuti cniitUMl noHtrib: Uie ■n'liWing md 
cry; tlw nssteJ body ; the writiklt-d and iudadio ckiti ; tliv hanwl 
redneiw of tfa« buttockit and perii)n>uiii' — all Ui«a» svinptniDs are suf^j 
ct«Dtly cluu'OctCTiHl k*. i>(>ii1>t IK oiily pL-rmuw^iblv wbrn thcsmipfaitnsBrs, 
few luiil indisliiirl, wbcu tiiilrilioii Jh uuii0i-ct«^l iind Uip aaia htm tlia 
&ppeBi-nnro of (sir beullli. luHudicuwHtherois gDH^nd paUor of tb« ekin 
and careful exaniinntion ujay <lc1«ct a fevr co]>perf Hpotti upon the bod; i 
Rhe ^tleen may It« bif;. mid we luuj, tH.Tljupit. diitcover some ai]a^eiD«tk,j 
»f the ton'«r ftid uf tli« liuoicrrux or sbafl of the tibia C'bronin coirn i<; 
timM the onlr Bi^ of the dtaease. F«rHiateiit rimdHiut; in l»ba«a jm-, 
iinimilv of h}-j>hilitiR ongin. If it be rouibiiit*«l with [vdlur of tbc akiu, 
Intnliiiriit tthould alwav8 bo ni1ti|)t«Hl, €«p«ftiiUv if a history ofprfr'-' 
vimm itiifwarhitgcs can be obtained from tii4> mother. 

la nlilfr cIiildreD the sigDS of past dtM-juM- art- : Ftattmnl brid;>e of 
be Doiw from loiig*coiitioued swelling of tbe luunl tuuctms memboue' 
rwben tlio bouoD aro soft ; marking of th« ukiu by little pita or deatiieeij 
from (ortaor ulcei'ation, especiollv when th«8e ar« eeat^nl about tint anglt* ' 
lit the moiitii ; pmtiibfinuiRP in tfie iniddlo line of tlie forebmd betwec 
tfao frontal emiueiK^t^s from «nccitie diseBsp of the &od1a1 boa*; enlB^ed' 
ii|)Wn ami mtii'ked pallor of the skin. If tbe penuaii«nt t««tti lure ap- : 
jK-ari'd blic iiiciiioni HboiiUl always be examined for (itgDB of liie cbarao-' 
lerintit! nialfniiiiatioofi. 

Ill oAxoft nlir-rv them is rnlar^ment of the ends of tbe long bunes, tbe 
(lin{^D<Kii)( frnm rickola baa to he mailt;. Aa vuiupart-d vcilL iulierited aypl^ 
iliH rii-ki-ta is a Into diaeoae. It rarely begins bt-fui-e ibe uiutb luoutlk 
11i(- IvaiooHofHyphiluiare Bceii early, altnoHt aln-ayti b(>roi-e tbe mlb tnoalh. , 
A;:rniti, ihc lK>ue oiKoM in a^-pbilia i« uauaUy e'Wileu<-« of h profouud caches 
tic Hiiitc. It is. tliL'i-ffurc. in most cMca nccoiupauied by otber nml <iu- 
ini!itakiibl(> hvtHplouiH uf tbv disease. MorcoTtr. it is rery mrtiaL ««Mota 
afl'<e<-tt< Ibo libit, hikI in not !iTiunietri<»L In rickets it is aJiv«.j-8 ermmet- 
rii-nl ntiil ^'ciu'nd and the ribn are tlie earliest of tbe bones to bcoffecled. 
lu h;,-] iliiltH Mt']i;inil iou uf tbo end uf tbe bone and Kiippuratioo around tlte 
joint are not uoramnion. biricketH these leidotisare nererspen. Agnin, 
llie prcliminnry aymptiiine of ricketa are verr cliai-nrteriRtic, and axv quite 
wiuiliug iu an unL-oni[>lirat<-d rii»e of iuberite<1 srpbilia. If, in any cnsv. we 
find that the bone lesiooH ore ity in metrical and lurulro tb<> cihIb of rU the 
lou^' bones, if there is an abaenoe of the eieus of inli«rit«d ^r^iii bat 
a bt)ttory of tlie symptoms charnoteristic of we cnrly staf[e of neketi^ and 
if m find that the ubild's dentition iHbacktranl. and that at teniDoiitbaold 
h* Is showing no diuponitioa to " feel his feet " — we diall har* little dilH- 
mltj in roadiing thr> rouclusion Ihiit tlitt caae is one ofricket& Still, a 
Biila form of ricJcetu is sometimea en^'mft^xl ujion a ai-philitic conBtitulion. 
Hers we shall find nyninielriml aiid genem enUrfjenw-Dl of tbe joints 
and bmding of tlie ribs combined with some of Uie a^-mplonui of presenb 
or puKt «n>liilili<' dis^aite. 

Dootylilis (K'ciiiTingiii syi>hilitio children must be distinguisbed from 

bo neenuiifl wbtch Mvint'liuieit attacks strunioiia subjeota. In sypliilis the 

'disHinril lKin« is vvculy enlarfirod. and no iuflamniatioD in the iaLeptraenta 

ooeur* unleas tlK> hizo of tbe luutp i?^i)OiM>t; it to accidcotal injurv. In tbe 

flbrouH fofin. olao. the aweUiag is isdolfnt and iMunlc^tia, and altliongb not 

i)iilla syuuDetriflal, tun in tbe osseous variety, is dii^tinguisbed by its btlle 

Undanoj to md in Miipptirntion luid absoe^i. Iu ittnimous neeroeis tbe 

it if uiir^ed uuuvenly luid guoeroUy fonub a lump on one aida This 




huD)) gbtA bit^^r, Uii'D Boftens and mippiirsteH, adh^KintiH talie p1iu:e with 
till" iutcgumcnt, and finallv tlie nlistrPNs oppnn and ilischsrgps cfleeitT |hih. 
On exptoring tlie abswus Ixuc Inm*? ir* found •it llie holtoni of tim tuivity. 
la all tbwe cas^s cari'ful iiiqiiin ><[i<>iild Ix- moklv for Li»tur>- or nlga of 
•j^liilui lu tilt- i>iUii.-iit or oiIr-t ciiildruii of iLi; fmuilr. 

frogauniif. — Tlie iiRijjnosiii is Mrioim in [trojmrlioii Ui the intenidty of 
1L* oatfh^xia. Tb» gc-nerftl comliliou is, tliereforc, of jfrffttcr iuiporttiuce 
lu oountin;; thp cJiances nf a cliilds reco>-eiy tbtui the seventy of aiiy par- 
lidilftr i*yrii))tom. Tiie dej^ee of iuU'uxitjr of tti6 cacbexiiL may lie «8ti- 
iuftt<id I7 thit dat« of n]>i}oiimQ(») of the firat syuijriorus of tbe <Its«iHe, and 
by the esieat to which nutritioa ih interfered with. If the s>'Riptoni8 H.p- 
pear durint; the Brat frtrtiii^lit and the child pingreiutively wnsti's, death 
may be antic iimteil wth <!ertainty. All intorciirmit ilonitij^ements which 
intcrforo vith ihj^Btion and OBsiniilntiou of food seiifiibly inorenso tho 
grarity of tJi« cuw.'. Tbus. vomiting aiid diarrhcra. which mpidJy reduce 
tbe 8treu|^b of eveu a healthy child, most be Eookerl upou an very uerious 

Diiwssc of th« infernal organa or of tbv bouett. ua they iiidic&t« pro- 
found cout&miiiatioii of the HytiU>ai, tualce tbu cumh a very ausiouM one. 
Moceorer, tbf> iiit^rftreuce vrilL fuai^tiuu whii;b rt^sulls from tlie viacemil 
dinWMW id auotber reason for fonuiug n very unfavourable opimoo as U> ttto 
result of the ilinefls. 

Thero is one special aj mplora which must not bo overlooked iu forming 
B prognosis. Tin* ist tho condition of the ntuml passngeA. Mlien these pas- 
anges are occluded from Hwelling and iiicruHfation the child ib forced to 
breatlie through the mouth. Con»e<)ueiitly, he can take but little nouriaU- 
snout, for wliile he HUckH he cannot breathe, and %vliiln he breathea he cAn> 
xtot Muck. The luuount of food he takea in. tbcrcforu, wry iund^quate to 
the wautx of bts HyHtoiii, iiiid bo in iu danger of m-tual atan-atiun. 

If the diseiibe firwt uppeiirH tievenil niouUia after birth, and if tbe child 
«ontinne9 nluiiip, and iIocb not seni^ibly emaciate, tbe prognosis in favour- 
able even aJtboii^b jmrlkMikr MyiuptotiiM uuy be severe. 

la caseti of relapse, or of »o- called delayed sypbiUa, when symptotiiK aj> 
pe«r ikft«r tha tievonth year, iniieb depeudti ujxin tbe early reco^lion of 
the nature of the nmliidy. Svpbilitic leaioDS urKeoUy require specific treat- 
loent, an<l the Mi-ndled t«rtmiy forma of the diaeafle rnDuot t>e iieglfcted 
wilhotit Mrioiui conHcipieneest. Therefore, to look upon such lesioa* sa 
acrofuJouA in their nature, to b« trf-ated with cod-livor oil and tonioa, U to 
ootnoiit ail error wliicb may be a very fatal one to the ])atient 

TrfOlmfHit.—ln every case wbere a woman givea birth to a syphiUtic 
child the uature of the ilbie»s( slioiild be cxplainetl to tlie father, bo tliat by 
euitjible treutniciit of one or boLli pareuta their future cliiltlrcu way be 
enabled to cacape the disease. Treatment begun duriuj^ prcj^uancy in often 
vuooeaBfnl in prerentine the taint fmm being tranBniitted to tbe fu<tUK ; but 
it ihould be begun early and, if it cau bo borue for »o long a time, should 
be coufinucd for fully three monthti. 

In the oliild it it important to attack the cacbesin at the enrlteRt i>oiiiu- 
ble tDoment. Therefore, if previous cliildreu bave been ej-philitic, and thn 
parent in the intenml have undergone no In-nliiient, it i» well to place the 
nenr-boni child nt onre uuder tbe intliieuce of remedies, even altbouj^b he 
may have a healthy appearance aud present no Hyinptoum of the diHcaso. 
McriMirv iit indixpen.'utVde to the aucci^Mifid treatnteut of tn^mtilo Bi'pbilil. 
It may be eitber given internally or applied externally. In I)fu] caaea it iB 
mil to ooiubino iuterual adiniuistnitioi) with external appUcatiou, ao is 





tn bring the Hj'Btcni iw quickly an iiowiblo uiidrr the influence 

The infntit: may be fd'i'en ouo grnin of gra.v powdtT twice a dav. cither 
ainiie or eoiubined witi a gmu of carbouate of jiolaali or a, fe«' gi-aiiiH of 
prepArftd clinlli to prevent irritAtion of the alimentary' cauaL After a week 
th« <1o«u can bu iiicrt-atted hy a uuarter of a i^riidu every tbi-ee or four du^ 
until two or tbrvti ^raiiie are taken twice n dny. If tiie pnvi'deni ])ro<luce 
irrjlation of tJie Btoiuafh, thev cua he omitt»(l for a day or t«o uulil the 
irrilntiou has subsided. If tuev sliU diaftgroe, it is better to diange the 
preparation of mercury. In tlus cAKe ])erchloridB of mercury in doses of 
twenty or tliirly drops of the ordinaiy I'hnmiacopa'ia siilutiou (gr. ,^j to 
gr. (')) OAQ be given iu n Icaxpoonful of ^-ater Kwoeteno^l inth {glycerine 
two or three times a day. Childrttn tfkkc thiH salt verr well, and it will 
ofton a^^ree when tlie gray powder exdtcH irriUitinu autf Tomiting. Ca]o> 
racl in iloKe« of one-twelftli of n proiu in aaumtinu-n preferred, hut it iit a 
more irritatitiR pn-jxu-ntion thau Lho other, 

Externally, mt-rcury i-uii l>f i-uipluytd iu the form of the ordinary iner« 
curial ointment. Tlie most convenient method of usinK this nUve is to 
smear it inside tlie flannel band wliieh covers the infaut'e belly. \Xhca 
thin i» done great eleaiiliueatt must be observed. Tlje whole Inxly niunt be 
wtuhed well «iUi soap and water every night so that all old uiulment is 
removed before a fresli appliuttiou iu ma<le. Another iniy of using mercuty 
extenmlly ia iu tlie form of mercurial Imtlis. Thirty to ninety grains of (he 
percldoride may be dissolved in two gallons of warm water. It is better to 
bepn witJi tbe smaller quaiitity and i^duidly to increoM the strcnj:;!]] of 
tlie solution. The baths, beud«« their effect upon the Kcnei&l qretem, have 
H very beueficinl loL-al influence upon the cutaneoua lenona Wlieu the 
cai-'hexia in very sererr-. it ia well to cuiabine externa] fvith iutemol treat' 
inetit ; and in enften Tvhere there is f^reat irritability of the atomaeb or 
bowels, wc mny be forced to dcpeud exclusively upon the cutoseouH ab- 
soqition of the remedy. 

1/ a mother who in giving auck to her dtHOased iuEant be herself under- 
going titatment, it may be uniiecessaiy in addition to give mercuiy to the 
child. Double have been entertained as to whether mercury in really se- 
creted by the breiuit. Cullerior baa t«st«d the milk of mercurmli^d uiotb- 
on witlioitt finding evidence of the druj; in tho secretion. Still, it seems 
certain that an apprrriable aniaunt of the reme<iy must reach the child by 
this means, for iii mild eaHea very rapid impmvement is noticed in his 
KVmptoma while ho remftin« at tlie lu'entrt. Li casrs of tievority I am disin- 
clined to trust to tliL- cUUd'n ^ettiug u itufficieuc^' of the drug by thifi chan- 
nel, luid prt'fer to h-iipplcniint the Irrutmeut by Ihe dirt-ct appUcalinn of 
men^urial ointment to the Hbdunien. 

While Hpecitic treatment is being a<loptcd, we must do oar be«t to im- 
prove llie general luiTriLiou of thf iiiftuit. The milk in syphilitic' mothers 
18 too often poor and ivnterj', and ill-adaptt-d for the supply uf mfflcieiit 
nourishment to their oflsjiring, Tbtrefort' if the child wastea, eii^eialty 
if, by frequently iripiiriug the bivrwt and crying pccviiJily after liis metd, 
he tjcem lo be ill-suliHtipd by the milk lie him swallowed, it iti well to give 
alt^-rnato nieids of cow'h milk diluted with uu vipiid <|iianlilyof borley- 
vrater, and containing a wiiall quautiiv of some malted food, such as 
Mellin'a Food for Infants. If the child Lave a difficulty in aucking. on ac- 
count of the condition of hie uaual passages, this food must be givun with 
ft enringe. If a feeding-bottle be aaed, core must be taken that no other 
child be allowed lo flurk at the mouth-pieoe used for the diseased iufant, 



md tlw nont •faonld b* rtM oo mi aot lo pot tht ImI into her on 
month, b cnaiiectiaD «ith tint aBbied. it n^ he well to rcmiii that tk 

U m dotr in «11 theie ^nca to w^m Om murm.B aad mmili in iwodMto 
■ttcodnc« apoa the eUd of the da«gvr o( mlacboD from a i »eo«» rwlrliiH 
nd other diadMKgng aono opoB the patient's bodj-. Hiejr dMivU bo <li< 
recied to obeaio ynaS dcaaliDcos ; to wniA mipti^ tfanr heads ^oa oj 
doth or towel oaea Cor the iaSmt • ■»] if tber hare • finger woondad hf 
aas aecedcntnl cot or aihamm, «a do feccooot'to hoadkuo ehiU nnlem 
the put if Deopcoj protected 

The inant nrast bekvpl perfeetlf deUL Hi« whole bodr should be 
bathed with «ianvBtertwie«» day; end if nkcmuut tnuodaoM mo beiog 
emploTod, mmf Aaaid be need (or the ercniag both. Can mnet be taken 
to dz7 the dttSd thoroaehlf •iter eadi waduog. Fteeh air is of the ntaoat 
im por ta aee. bimI if tb« paii(-oi W- siniog (-oouk^ end die i*«atber drj, be 
coo be taken oot ereir <l»r wanul; drcseed into the airji 

VomitiB^ M beat ticaled In- sa^Kodin^ the mcRorial lor a Caw dara. 
tt the qmptora nmtfiwio and there be ■ eoor entail from the breath, the 
diet Buat he Altered, »e reeommended in soeh eae«» (se« lofieatile Atn^vL 
If ioo mnaaB oi the bowebs occur aiod be not arreeted br stnpptng the moot* 
eine; an alkah with tinetme of catet^n will luniiill^ ch«ck th« lUnagamant 
at once. Dianhaa ia aeldoBi obatitutA in thft«e cam* if tiM diet be regu- 
lated and the cfaild'a bodj b« mSocnLlv protcctctl froni tho ookL 

It is important to attend to the oDoditimi of the nostrils. All hard 
ertuAs most be remored br hatbing with warm water aftca- Hofteuiog with 
cold cream. An oi&txaent of the r«d oxide of asereuiTt' Dtay then br nn- 
ployed to the in»ile of tbe ooatrtla. Hucooa patches must br wtll toarbod 
with the »«oliil nitratH of lalTer, and if lar]ge ecthvinatous entstB have 
forme-i on the bodv, tbev must be remove I^ poulticing. The onoovered 
alcer can then be tre&t«>l with tliv m\ rmrrcurial oiiitm«ut> 

Internal tmtin«nt must nut be coDtinucd lun^ aftt^r tbe sjiBptontfi of 
the diaeaae ««A«e to be noticed. On aocoont of tbe profound Auuniii oftMi 
indooed by the loog-con tinned admiaistratioa of mercurials it ia wiae lo 
change the treatment as soon as the aldn baa reoorered its healthy amMafw 
nnoe, ami the other ^lecific ayraptoms have 8tibeide<l. Cod-liver ou and 
iron COD then be giTen. In addition, every care must be token to pronkota 
healthy nutrition by jadicions regulation of the diet, and vigilant attention 
to all tbe minor agencies which exert so material an ioflueoce upon tlie 
vell-beina of the infut. 

part k. 




T'JilimfflBI""" (leakli-TToia), idUioufrli n rare diaeaae in cliildhood, is oo>| 
aiiSiliSij nean ill tlie TOung Rubject, and tlierefon' may be Rhortly d( 
Hc.ribr'd. Th(^ disi^iiM' in chnrnctarisMi by grcttt eiocsx of tli(^ lt>u<x)o,^1fle < 
tho blood, oTilargriiicnt <>f tbc Bploen. »oraetiin«B of the Ijiuphntic f^lADdfl, 
luid u niorbid stiik* of tbo bouc uirilulla. Two ctusea liaro come iimler nij ' 
noticf?. l)oUi in ebilJreii iin Jor ihrce jenrs old- In each of these the mabdj ' 
■aaumed a febrile form, and was sceooipaoied b}- enlargement of iho i^Wn 
without niiy ai>p(U'eQt aflTeetiuu of the lyuiplmtin gliUKld. In l^uiphtulviiomiv 
which is ddBL-ribed elsewlurc, iiil iiicrea^i il tho iiuiuber uf the white cor- i 
pu&cleH iti excepliouaJ. Sometimes, howewr, iii that diseAoe exceauve over- 
g^o^^lbof h'mphjitii,-clemcutuiH oombiaed nith mullipUcatioD of tliec4^0tu> 
less bloorinylls. Thefie c-asp-a proHent a great. reseniVilaiice to the iTtnphntio 
form of kui'0(;ytlio)iiia, and, indrtHl, anatomionlly npitear to he almoet in- 
diBtit)(^iishabt& from it. In th« prcKout chapter the ^ttetiic fonn of 
leacocj'theiuia nil) alone lie desctibed. 

Oatinatioii. — The etiology of leucorj-themia is not clear. Out of 150 1 
cues (uialywd by Pr. Gowors iii ouo-foiirtb Ihern wn« a histon,' either of j 
oguo or of habitation in an ague district. Of my own two cbsc«, one hadj 
lived at Malta; the otlier was a reaident of Lomlon, but hA<l lived in b' 
strciit in which tlic roa(Ii\-ay had been broken np foi- repairing aiiit relay- 
ing diointi i uud for two or throe mouLhtt the upturotd fioil, tMittmite^l w-ith 
ooul'ti^ia and other unhi-althy eflluvui had ifmaiucd hoiipcd up by Ihu Hide 
of the foot-pavement. The disease appealed shortlv before the close of 
tbese operations, and I cannot but think that, the illness took its rise in 
the olTeuHirt^! emountious to which the chihl hud been roiiHtantly espoacd. 

Morbid Aualumi/. — The spleeu in eulargi'd and uuiy reach a >n%at size. 
Tliit) increiiae ia due tt> au ov*r^owtL of (be wlenio pulp, the leucocytea 
and tho librous staroma being etjually iucreasetl. The organ, although fi»- 
larscd. retains ita nonnnl ]>ropnrtii>us, so that its shape is not changed. lis 
density is inen-ascd and its iiilitiir w paler than naliti-al. On the surfnce it 
is BmootL uiil««s local poritoaitia have occuirod, in which case p«a1icIos of i 

lyuijtli may (wllK-re to tlio cnpsule. Frtan UitH rause it may contract ail. 
liesiuns to porltt in Ha ueigbLKiui-liwxl Ita ftc<!lton in kdiodUi hhiI of ii 
brownidi-TeUow' colour mottled irith jwjvr tttrcaJut from tluckctiixl iror 
beculati and but little bloucl ettt'spe;! from it on preHsam. Tbe Ikfaljiighuui 
bodies tuv not rf i-^- pi-ouiiu<>ut, uui) lusjr be hthid undrr the microacope 
U> Iw the nest of fiittr or limtooeous degenwntioQ. 

The liv«r is o(t4-ii unLirged horn coogestiuii. anil mny hu hUj. Tito 
tddncja. too, ore alien tlus Meot of fattj^ aegimemtioii. Usmorrltogic «x< 
travaeationti are cunimon, and mar he ttecn in the dda, tbe heart, the 
longs, the brain, anti the retiim, aotl tluid uffiiaiotiB may be found in the 
MlWis catitien. 

Id borm onaaa tbo Ivrnphatie glands undergo alight eiUargGmeiil, but 
11m tnereaaa id dxo ia rarely tmiTereal as it ia in lymphad^ionui. On 
examination tliejr appciir to be nonnnl in Rtiimtiire witliuiit any bjrperjJa- 
MB of tlie reticubim. nud RUpptiratioii or «A.Hent9on I'aroly occunt- Am in 
lvniplia<;l<'noinfi, adenoid i^ivtliR may bo also found in the tonsilm, tli« 
f(>Uii:U''.-4 u( tliD tou^uo, tlie i;Uiuda of the stoinach and Intestines, and ia 
other tritiuitionn 'Ihc tupillaries in vnrioua parts ara diateBded with col- 
lei^ooH of lencooyteH. Tbe morrow of the bonea ia more fluid than nataral, 
ia grajish in colour, and allows im aiTumulalion uf white and n^l corpiu*- 

Ijfdm. Tbo blood itself in much tdt(.TC'd. It in jnle in colour, coii'^ulfltt.'ti 
■air, aud bIioits uu euonnouii (?sci-wi of white corpuscles, togetht^r with 

'n diminution in the number of tbe coloured o«Us. Conaequently tbe rel- 
ative pronnrtiooH, ia8t«ail of being 0D« vhileto four Lunt^lred nud fifty red, 
as in he^ltb. may fall to one to tweul;,-, one to ten, one to livt-. or oven to an 
actual t>iiiiiilily of uumbfir. Tbe whit« oella luay olao present pecubar char- 
NCtcm. Tlivy are sometimes aeeD of two quite different forum ; tlic one 
double tbe size of the other and ftiU of wniUl fat graniilei*. Actronling to 
Moeler, tliis larger form ia evidence of luorbid change in the bono modullik 

^^JUter death thick (rroamydooking clots nuty be found in the cavities M the 
the lermiuol branches of tbe pulmonary artery, and the systemic 

Si/mptama. — The illness begins insidiously. Sometimes at tirat the 
generul health idone sucms to bu iiiipuirud ; somctimirfl even from the be- 
ginniu<!; tbe IwUy is uoti<.'«i«1 to be large. The child luHen bis spri^fhlJiness 
Rud begins to look pale aud to droop. Hia appetite fails and he Hlowly 
wastes. There is aluioat alwavs more or less fever, but tliis in at first 
sli:ibt and occui-a irre^^'ularly. .\fl«rwiirda it beoomca more coutinuoua aud 
tlie loiiiixiratuw rifMis lu n iiigbi'r level 

Enliu^omont of tli? sploen, although not always noticed at on early 
period of the disease, is usually lo be detni^l^d on rju'eful examination. 
The limits of tbe org;m Rliould l>e always efitiiitated by jierciisHJou as well 
OB ]ialf>atLon. The dcf^c o( r^nlnrgement vnripn. lu neither of tny cnitea 
did thu lowor vdsc reuch mure than three tinfccrs' bi-otdths below the ribs, 
■nd there did not Hoem to be any great upward extension. In many cjwes, 
however, tbe increase in size is much greater. Some enlargement of tbe 
liver mny also be noticed. 

^^'heu the disease is fully developed, the cliild is polo and weakly look* 
ing. Hift complexion is very while round tbe moutb aii<l eye*), aud at th€> 
Bides of the iiom> ; but often tUere ia a dunb uu the cheeks, which at times 
ia noticed euddeuly to di-'vippeoi*. kiiviug the face ^btwtly {jnlc fnm tbe 
eontrast. Often, especially when tbe disease is advanL-ed. there ix ii pw'U- 
liar sallow, half-jnundi.-ed tint of the skin. This Ims been iiltril»il''.l to 
tbe amuiiua, the ulterud Uuud being unable to Jeatruy the bile pif^iucut 



nltporlw-cj into it honi tho intwttjiio. Tlie belly ia umially awoUco rrom fl»tu, 
Icut iu.-ctiiiiiiliitioti, iiK well iiH from vuliu'gcui«nt of liio Uvt^r uiil tspliya. 
No tt-ittUmeflH i» noticed ou ))»siiun< ■>{ the abtlomea, but if the bone 
mfKluUit is (.liaeaaeil, piuiis in tii^ Uiabs may be eompluood of in voUtini^, 
Tliurb is no lotta of eiudlicity of tliu tikis. ' Tbe tougutt is furred auJ tLo 
IjowL'lit art!; ottcu uLpriciuus. Humctiiuca Uie stools iu« looite Aud sUiuv ; 
at oUier limee Ibere in coofitipation. Tlie child uui^' cough, mid his breaUi- 
iag autj be slioirt ; but ooioaci a compLicatiou be preeeut, examination of 
tbe chest ducoren merely a littJo liuxc^bubblitif; iTioucliuti nt the buses ofl 
the lungH. Tbe pulse is quick<>ae<i, espec-ially at uii^bl. It itt UKUjdly overj 
100, sometimes conaider&bly ■*». In owe of i«t cases— n Utile boy age4i 
two yeaca aud a quiu'ter — Iho uriui- wtw liij^ili-^oloured nnd offensive, aud i 
O0Dtain«d bil«. but nuiUbuitiHi]. 'Xlierti was some diltU'uliy iu hoUliug it' 
nt Qiclit, 

Tlie tenipcrature rises in the eveniiii; to botvreou 102" and 103°, sink- 
ing to 9i)' ill the moniiny. The fever, however, ifl rerj* im-guhir. imd on^ 
some diiy» is iiiurh hi^iier tltoji it is nu others. The skiu luuy he moist 
at iiif^ht, and ROmitimen thero is <-opiotiB pcrapiratioQ. An examination <>( 
the blwid discoverH u (*n-jit fscem iu tbti number of the wbit« corpuscles. 

Am the diKease goes ou the child remalna -my fretful and piuiug. He 
sleeps biuUy at night and continues to lose flesh. Hit; espreisKion is vety 
distrtiosed, aud his face is wbit« and haggard. He is tluisty, but cares < 
little for food. Oft«u hiL'tnonbages come ou, aud Ihvse eflVisionit form a 
very cbArncteriittie symptom, Tlie uoea muy bU^. or blood may 1>e ilis- 
charged by the mouth or bv stooL Although usually a late symptom, 
hfeaiorrbacD is not always delayed until near tlie close of the illneas> 
Epi!ilaxi.s is sometiines uotiocd (juit*^- cdrly in the diseEiae. 

Knlarf:;omcnt of lympbslic f^lnndfl inay occur, but tbia is mrclj oon- 
sideniblo in a cuso of pure siilenic. Iciicocythcmiu, and prcsAuro signs txami 
this cause are rarely noticed. T<)W.-u-ds the eud of tlte discam* tedema and"* 
dropsioiU eflmionti are common. There may be aarites or hjilrothoriui or 
u-dbiuit of the luu^r, aud ILv lowt-r limbti may itwcll nud pit oti pi'efsurt-. 

The feviT uHually iJC-rHrverus to the end. and the child groH'a thiiiuiT and 
wetLkur. Various uomplications occur before the close, I'sjiecially croupous 
pneumonia and pleurisy. Death is often preceded by an nttack of convaU 
sions, due, probably, to obstruction of tbe oerebnd oapiUaries bjioaaaeSi 
of leucocyte*, lis tl^'wribi'd by Buxtian. 

Jiitiymmn. — Tbe ^-niptoms of leucoc^theioia are suffiiaAntly darwtvr- 
istic of the disease. Im^gulai- pyremand general impairment of nutri- 
tion, combined with a dinti'essed, pallid face, a aoUow nomplexion, n 
swollen abdomen, an eiilargod spleen nnd li\er, and the occurronco of 
Apifftaxis or nicliviia, point very distinctly to loucocyitioniin ; and tho 
diagnoHis in at ouct^ coufii-tned by a uiicrDHcopicol examinittiou of the 

When seen for tho fiiBt time, the case oftc-n preRcnta some resemblaooQ 
to enteric fever ; luid n hu-morrba^ occurTin*^ from the bowels mi;;ht 
appear to confirm this i lev.- of the illneiis. But the histoi^-, which uimnlly 
iudifjites dineaBc of considerable etanding, the comjtieto ubaence of m^ 
q}ote, the enla r gement of the hver aa well as of the Kplucn. tiic peculiar 
aallovr tint of the akiu— these symptomH arc very unlil:ft typhoid fever ; 
and if at a late stage <]Mlema of tho lower limlK> oc>cur», the presence of a 
symptom so uncommou in enteric ffver should mi\kv us at least doubt lh« 
oorrectjiess of this dioguosui. An examination of the blood showing a 
targe «xc-«s$ of leucocytes is of cuuriie condusive. 

Ij6iiroc>'tlieiiiia iiiny be <U»guofiei1 with cortaintv if. with :iii ou]nrge(l 
Rpleeu, tU« piW(iurlioii of (vi|oiirl»w forptwcles is greaXer than one to twenty. 
lu i\ doubtful discs tbtrcfort!, it is well to count tbe corpufirlen with Uie 
fanmflcjrtoiat-ter. If tbc jmiiwrtion of lfiioocyt(>»* w lenif IImii one to twenty, 
tiie COM may iitill l»o ont- of knicofyUninitv in [>T<j)r««s of ilevylopment ; an<l 
08 Dr. Qoworfl lia.4 ])oitttet] out, to e\rlu>lr' tiiis iliwH^c il will !>« necessary 
to mnVe n^enivil cxniniiialiou of tlip Iilnnd, luitl untiKty uiirselvCB tliat tli« 
proportion l« nut iucKo^iiij^'. 

Id caaes whei-e tho lymplmtic ({lauda undergo ki*petplfi8ia, the diMAse 
iBdistin;crui»Vi«>il frnm h'ni[>nntlenoiun by notiriiii; t^int tlm lymplmtir en- 
ki^gameiit in only miKlBrato, ami ocoiirs as a Into coinplifntioii. AIwi that 
ibo OXCO0S of white cori)U»)cle8 in the blooil is vorj' i>ronotmo«il. In lyrii- 
pboilenoua this increast- w eitlter alHwnt or is compufativcly iiisigiiificatit 
Composite casein are, however, ocvoHionally met with, luid uay lie ft Houroe 
of ]»rplfixity, 

PrO</wMig. — Tho iUa«u»i invarinbly lenriiiintca fatally ; ftuO tliti uioro 
neurly the number of thu wluto <.'orpii8ck*a in titc- blood approaches to iin 
Hjnidity with that of the red, the greater the pros{j»'ct of an ewlv tenni- 
DKtion to the illD«iiS. Hwmorrlinge, onlees it be &om the noae, la a rery 
grave symptom. 

TnmiiH^ia. — No troattnout lias yet l)e«u <li«corereil vrliicb is capable of 
anwitin^ tbu profifress of tho i1iHpa>io. Arsenic, which \» of grGot vnJuw in 
imnm of lymphndenoma. has iio iatlucit(ro in lfUCO«ytliemia, and quinine, 
iroti, and tonics penerally hiive jirnvetl to he quite unless. Cod-Iivej' oil 
may. however, bo Kiv«n, mid in said to he sonietimen nf temponiry boticllt. 
Id au early stA^jo of tho illncan fftiivli.'«ttion of tho Hpirni<^ ro^ion for liftcvn 
miniiteH twice a day ia Hoid to diiuintiili tbi- pi-opotiiun of wliitc corpus- 
cles in the blood. In a caae reporU^d by if'-xlfr flus application, com- 
bioed with the internal ndministrafion of piiseriue, oil of eu4'alyp!us, and 
hydrocli omiti of cjutuiiie, reduced the eixe of the liver nntl Hpldou and 
greatly iin])rr>v('d t!ie condition of Uie blood. Dr. G. V. Pooro findi* the 
€M tb» ti[)li>eii to bti diitiiniHhod toniiMrnrily aft^r farad imLiuu, but 
that th« therapeutic bcnetit derived from the application ia very 
fau^DL Many timea a Rplaen which wiui felt to be bnialler and Hnftjcr 
immodiatelv after (fulvmiisin wnu found after only a few lioura to have ■ 
I»<OTered it« former «tzc and agaic become tonne and hard. Dr. Poor* 
Btatea that the leiicocyicH in the blootl are inproased in number directly 
aft«r lh*t applii-alion. Injection of VTiriouB HubsbincpH into the Bpleen 
bMQ atU'inpt^nl, Irtit the renultw have not bt'cii eiK^oiimjjin^. A cano is nv 
poited in which ii •^rtx'ia imd iv linJf of ualii'vlio acid wan iujvctod into the 
organ, and the patient died tii\ huunt uftviivarda 

Kxdaion of the t>j>leeii bfUi been tried, but htiti iuvariiibly ted to Klieh 
eflutnOu of bloo^l that Ihft death of the patient lias rery quickly foUowod. 
All wu uin do is to trval <1iKtrt;-imiii^' K,viiii>toniit tui they »rt»e, iviid to ttup- 
ply tbo patient with f>ueh DutntiouM f'Xid n^ liis stomach can dij^t. Quiet 
ifl Tenr important when tlie aoiGmia ia ^re>st. LooaeQC«s of Uie bowels 
moxt W tnuto^d with sinnJl dotw.-n nf rhulmrb and the aromntir chalk pow* 
der, or with dilute Knlptmrie acid ; cedemn with digitalis and dtiu'etics ; 
ttfHnocrbnge with the ordinary rtyptirfi. If the pain is complained of over 
Vb» spleen, itia liest relieved by oount«r-irritjitioii and anodyne applicatioae, 
aach na fnnearin<; the surface wiUi eipiid iKLrts of tlie extract of belladonna 
■Del gtyeerine, coToriug the side afterwurua with cotton-wooL 





LntPHADEniMA (ftdflmia, IjinpliAHL- nniPtDia, Ho<1gkin's (1i8i!itM>) is one 
of tlu> l«sa common ilinenMiR of vm-lv life, Imt it o<<(-iira HuffiMeQtJj' often 
lo render the afiecfiou a not unfaiuUiar uiir in Cliili.lruu'8 HuspitHb. Ljm- 
Ijlmdenoma rainsista in n liypcri''""'" 'j' lyiu|)hiitic tiiwuc in rurious jKUia 
of tlio body, f-vea in (dtuatiuiis when? such stnicturet) do not Dnrnuiily 
t'xisi in tuiy i^cnt quiuitit^-. The lymphatic {[laBdit are chiefly involv«<l 
but the spleen, Uvt-r. uuJ kidiii^yii may 1)« f^roatly cnlurged and alttird in 
Rtrucituif. If the enlarHi>nit?nl Iw limitfed to a ftw glands or orK>uiH. {be 
dinorfUr may have the rhaiwtcrH of a local complaint t'smiUy, lioweTer, 
llio iLfr<c<:ti(jn Kpreiwlii v«i-y extensively and e^Iiibittt all 1 \iv pliiiiiAUieua of u 
general diHease, beiuj? ntteixled witli fever. u-tMtin^, ^n>«tt mid inrrt-iutiug 
pallor, and marlcQcI weiikne«a In the end it ui almost invannbly fntaL 

CauatUion. — The causes of lymphadenoma arc obscure. Dintbetic t«n- 
(l*?uctefl bare been fiiippnsed to give ritte to tlie dtaeaHe, and there ih no 
doubt tint in aoino rhmrm pnlmnnmy txntmuoption or R^-pbiliii Iia» been 
notocl in the pariMitft In otli^r easps, howoT«r, tiio family butlori* bu 
be«u good. iVcute diflcose in tho cbiUl himself baa aumvttineH uiptwred to 
be tlie Ktarting-point for a slnvf delpriorntion of health vbicli aim eTeiit- 
ually (Icvi^Ioped into undonbtcd l\'niphndenomn. So &lao the occurrpncd 
of tbu ilUicsii boa bc-cu nttribut-od Iv b(\d or iuaailicicut ioo<l or iueauibiry 
couiIitioiiH gencndlr. In houic (.'hhch, botveriT, uo eutKcieut cauM bna 
been disrovered ta nceount for the failure of healtb. The dteeoae, like 
liibereulotda, with which it presents certain affinities, may develop without 
apparent reason in a child whose lieallh ba<l pre\iouhly given tto cause for 

In not a few ctwes Bomo loonl dcranfi^mpnt or injui7 has npimorod to 
be the exciting cause of tbo enlArgenient of th« Iyiii)>hitlio pjlaiifw. Tlam 
u derATed toolb, a pntrb of cczctnu, an oturrltcpo — idl tbcMt have been 
known to be quiekly followed by a swellitigof thegkuidH in the ueigbliour- 
bood of tb^ iiTit.iiit. In sorofulons Biibjerls a pArHistcnt caseouR enlarge- 
ment of ^Iniids fi'om tbin catuie in nut uucoiuuion. In lympbailcDDiDn, 
however, the morbid cliaiit^eH do not n-main UmiltMl to the neighbourhood 
of the irritant. Others more distant from the sent of inritatiun take on 
tbo Bomo uiibealUiy action, and tbtui the diaeaM spicaUs widely M ua to 
invt^Te aduuoid tiawuo in ^I parts of the bcxly. 

Tlie age of the rhiUb-eti aifecHed is UKually four or five yenrs and 
tipwiurdik X have, howoTcr, tf««u rt well-marke*! cam in an tnunt eight 
montha old, who hard begun to suffer at tiie age of tiiree and a hall 

Morbid Analomij. — After dentb iu a. case of lymphadeDoma we usually 
fiud great enlargoiuent of the lympbaiic glands, nwt often of the spleen, 
the liver, and the kidneys. In additioii there Is commotily oreiigTowtli of 



till* more minute rollivtioiiH of mlenoid tiRsiK^ in ^itrioiis jiarlA of Dip bod^', 
aa iu lli« luuailSp ibe iftiiu'^iis. tlt« giiUot, the Htotuaoli nud tul««itiiic«i, etc. 
Of these the more coi]n<l(tntb)e oiilftrg(«metit« iiro often Umitod to k com- 
piniliitlv (ew nrgima luid utructures, Imt microBcopical esauoinatiou di»- 
cox-erB rerjr widfffipre»cl chaiitj:«8 in jiiiiisi which present little or no appaieot 
Blt«iulion tu the tintiHHislJxl nifi^ht. 

The IviiipIiAiit; gluiKln 01*6 f^reatlT enlatifefl, and thn enhu-geiuent Dlf^ 
be in two lorum — 11 hard ami a Noft swelling. This diOlertiucci appanra 
to dep«Q(l less upon tlio nutiin?' of the (growth tlia.u iiik)ii tliu raijidity of 
it» progrces, for the two voi'ictictf may ha found combined in tJie enme 

The size of the swollen glAuils cnmmonl^ xiu'ies froia a luizcil-niit to a 
ben's OKff, but in exceptional cnacH tho prowtli iii«y rcnoh *[tiU mn»f coo- 
ndemhtc diuioiisioiis The lint (jlouds tu hu uflL-cti-d iltu usuulh- Ihttw iu 
the neck. Then follow iu onler of frequency the juillaix, iuguiual. reti-o- 
peritonRnl, bronchial, uiediaatiual, and meKeuteric. liut be«id*>B enliLrge- 
mont of ghuidti, circniuscribed growths may be tlevulupfid iu spolu wliero, 
slthiJUgh ftdeuoid tiHsuif exiutH iionimlly iu Miuall quuntitv, it in not eol- 
leuted into ^laudiiliLr m&tiuos. By Ibiu ihvuiik tLi« viu-iouK groups < if uulArgcid 
glands may be found connected together by chains of newly developed 
^mplintic uodiileH, * 

When n ;;rou]) of f;Uiuhi talfen on the morbid process, the iiidi\iilual 
bodies at first r^nimu (ii«ti»ci nnd n,rn movtihlc. A» th« dteooBe progreewM 
they cease to be movublo, uud evoutrndly boc<:imo welded together into u 
BoUd ni«s». The prore»i of union coiisiiits iu 11 disiippenrance of the cnp- 
BOla, which Ixwomps pieri^d and uUimntely obnoat destroyed an ttio new 
Ijmphntic tiatmo uociumUAtcii. Ou oxamiuiug nuch 11 miuw the outline of 
oisKHwd glands cnu be rocogniiscd bi-re aud tlierc by s tliiu fibruus enpeulu, 
but the coiiflnenee ia for the moat pKiL couiulete, and no inlerxeiiing inlil- 
trmtion can be diBPOvered. On tho tiur^e the maaa in often very irregular 
aad noduhitol. and mny he mottled with ivhit« or yellow ]jiU«1iph, but 
eswatioD is a^ldum m>Kn. If the iiiiwsa Ijo siiperticiul it may be adherent to 
the akiu. In mm ciwex it Hiippunit4>d 'Die greater or lem hardiieag of tlie 
enlarged gkud ia determined, as hati been ah-etuir &^<1. by it« rapidity of 
development- If it grows very ()iiick:ly the t^loiKl is wjft.. On seMion of 
nich n ^Iftud tlj<.> etibHtiLiioo npjifrmt oftfin to l>onbiii)i4t ilitHuonl. If firmer. 
it yields a creamy juit'C whou Bprajjcd. If vei-y lirm tlio hiu'dtiean is found 
to be due to hypf:r|>liuiin of tlit; tibroas stroma, dense baucht of fibruuu tis- 
me runniiig iu various directiooH through the mana. 

Undftr the microacope the luorbid change in ttift glntida is seen to l-ou- 
inat iu au cuurmoui iucreuiM iu tho lymph corpuiKJu^ Thew> ai-eumulate, 
and by tbeir pressuru may j^wrifonitc the capsule aud cvi>u Mplit up the 
BBpta anil eau»«e tlieiu t«i dii^iimear. In the aofter growtliti the disenitod 
proe«t» ia chtetly of this kind. In the fii-nier fjlaails there ia an increaftc in 
tiie fIbruuH tftmma, which becomes ^^reatly lliickeneiL The hypertrophy 
may eveu ubliCerat« the meshes of tJie reticulum aud oouTert the organ 
into a niABB of librouB tismie. 

The irjjtiren commonly aul^ra, especiAllv if the diseoso bc}^a in tUo 
Ijrinplialic glands of the neck. The organ liemmeR greatJy cnlnrt^d. Itit 
BDfnial lymphatic tissue lakes on a rapid growth, aud allows the tuime ten- 
dency to fibrosia tJmt i» noticotl in tht glands. ExtoruiUly the organ in of 
a duU reddish colour with piJor ])ntrhcM. and yellow KpotH fmni the aixe 
of a mustor^l^Moril iipwunls tav oflpu aeen Bcattered over Ihe siu-laro. To 
lUe touch it is ujwally <Ici:u»o aud tiru. Un section whitish or yellow a 


ulf9 nro (Jiaontfrcil on a dar1:-re4 gw>ond. Tho nodiiW aro luorc or lees 
cltiHcly i4,'prttjiitp(l >4) oh to form masaeB of viu-yiu;^ siw mid Kliupe. TTie 
new lonterial appfiiu's to origiiiale in Uie MiLlpi^'liiiu) foUiolt^s and llie jM-ri- 
nrlehfil xiinatJiH of hiiiphoid tltwue. It is computed of hiupboid i^vUk and 
largp quiuiUties uf imporfvct libruuit tiasue. 'Hie fibrous struiuii in often 
tliickened, bikI mny show IihikIh of 6brous iissae without dditiite arrauge- 
iQfint, or running Icxxicly parallel ho ilb to form otitl loc-uli by Ui(>ir divtr- 
gcucios. In n tuti- ntnac tbo bniida nre aometimeB }>igu«oti-<l nt tlicir 
edfiML TTuder tint niirrcwropc liii-sc Itftuds njipear to he foniti-d by rapid 
induration of a lympliiLiic LiBfiue growing iiroutKl ibe v<}MM.-lti. 

In the liK^r the new jjroirtli nsually appear* in ill* fomi of etnall, iireg- 
ular, iDflltratiiig miinace vrbich nuiy project as irrrt^lar pi-ontincul pntcbes 
on the eurfnoo. Tliu Rlniolure of tii^ne gronllia is similar to tliat of tlie 
new nifttoriftl in uther piirta, but iii iLis orjipir tliii-*' nppt-iira lo 1m> it prMter 
tendency' lo (^HHGatioti. Tiio Ijinpliatif new gnjwtL oo«.'upicK ihv inteilobu- 
Ur ifMures. In a cane rcporle<l by Or. Orconiicld it HL-cmcd to start in the 
portal eanolR an amiLlI nnuises whinh ost4>nd(>tl ai-ouud and iiito the lobulM, 
tbe livor-cftlls becoming decotienit^d and Bhrivelled. 

Wbou tbo fcirfnt-yx aro aflecled tlie organs are eutiu^d nod nftm iireg- 
ular in ahnpe. Their colour is light yellow or ev*u (lull wliile, and ec-chy- 
moBM may be Hcatter^d over tbe Bur&c^. Sotuetiineti eignH ol more profuHe 
luBOiorThuge ore foiuid, and large purple blotch^ are eeen lUrougb the 
ciq)Buleon Uio ])»]« surfacvuf tlie glnnd. On itertion tbe cortitxl hu Instance 
is more or less sweUod, and is of a voIlowiiili-wliitA colour niottlrd uitb 
pointtf and patclies of rod. By tL« uiicroscupc im excess of adenoid tiasue 
IS seen lK<tn-een the tubules, fionirtinieH. Brrpnratiiig them widely. The 
growth in cnlleetpd in Ini^e (juantities around the' glomei-uli. kikI in somo 
caRoa tb« now tiaeue appcni-H to \mi-n alonf^ Uio vetwels into I he interior of 
the Malpigbiim r.apsul[\ lu botli liver and liitbiovK it in couinton to find 
Wood-vcjisels bloctf'd by umascs of colourless t-oriiuKclcs. 

The new growtlia d^'xelojted i:i plitct- b wliei-o »l«uoid tusiue exists nor- 
mally iu minute quantity ai-e iieiially i-atlier noft and elastic. They are of 
a pbikish colour mtd very rusciilar. Such local (levelojmieiits of l>iupbatic 
titMU« may bo mvn in tli» tousik, at 1h« back of the ]ilia]'j-ux, nud tu the gul- 
let, stomach, nnd intestines, originntiBg in the follicitlar glands. AH theae 
often uniler^'o ulceration. Growtlia have aleo been found in the tcfltivJen, 
peritoneum, omentum, pleura, and in the lungH. In tbe latter atoatiou 
they often bivtUt down and form oavitioH. 

^Vhl>u lilt' blood is fxamJDcd laicroscopicaUy ^« red corpuscles are 
seen to be ven- pale in colour, but they usually form rouleaux in tfao or- 
diuary manner. Amongnt tliem are Porpm<eleH of much amaller diameter. 
The red cm-pnacles nre crmsidf-rably re<liioed in quantity, but there is sel- 
dom any m»t«!riid iiddiiion to thu number uf wLit^- curpuMt-lus: indued, in 
many nutirM, like tlio red celU Ihey are dimiuishf^d in number. SomL-tiuies, 
however, tbe leucocytes may appear to be nUyhtly more numerous ihan in 
the healthy subject \ but «V6U if t^io splet-n hv gri'ally enlarged, uo increase 
sufficient to foiiNlitute tcuotemiii is observt^d iu cnsBs of tnu> lympliade- 
uonia, and tbo whitH cells never present the altered cliHracLeni nliii'li are 
noticed in the former diBeose. Aa a rtile, a greater excess of white corpus- 
(■IcH is Been in caws where tlie Ii'mphntic givi^rth is of the soft variety than 
where it is h»nt imd cliielly tibrouM. Forms of mixed tlissase are also 
ftonietimoB met with in which there is inci-«ft»e jn quantity of tbe Gndetue 
pulp. Tbe alTection lias then some of the charoctere of leucocythemia. 

Symptoms. — The tij'mptoms of lympbadeDoma may be ilivided into 


tliow proper to the illnpsa, n-hii;h may he cnlletl Uie n-gular sj-mptoms, 
and thone nbifili nm irrrgitlni' and aroidf^ntol, being the conReqaeaoc of tlw 
pr«MUrc set up I>y the ^'ovrtlw upciu the portd uroiiml. 

Tbv jvyulur Hvinptutus cotiMuit ot the geuemlooastitutiooAl disturbanro 
excited by th« ilitieaiie, tli<> t'li;uig<^s ui tli» state of ttie blood, and the proK- 
«oc« of eolarged Iv*nipbntic gliUKlu. 

Thi- t^fucral (.■uuslitiitiaiml nyiiiptoitia ni»>' precede i>r folhjw ai-^H of 
tnhir^'Hiiieiit ui (fliLuihi. TUtiy consist of » febrile luuvatueot mure or leSM 
high, with gmdu-iUy iiicpetising waaUtig'. pallor, and Iosh nt Hlreugth. 

A little hof, agwl Ihn^e yeiirs, \v»8 iiitder (he fJire of my former col- 
l«s^ue. Dr. Alitcholl Bruce, iii the Etwit Luiidoii Cluldreu's HoBuititl. The 
child had bfroii ill mid hLo^uid for three nioiithB before admhKnou, gradu- 
ally wastiiir; uad ^uScrini; from occasional sttftcks of diurhcea. Whon 
brought to the linspitjil he was weakly, with n pale nomplfxtoii iind hnf:- 
l^rd, anxious liiolf. Hitt bice oftoii thiii.hcd up Kuddenly; bis mkin ^euer- 
nlly WOK IiotbIi nvd dry. At first do special disefuw of or](>iiii« coold be 
duicovercd. The Hplucu could he felt projectin}* olM»ut half aii inch below 
the ribs, the Uver vraa tiormal in otb, and no enlargvinent of the Ivm- 
phatie glands was noti^-od. The boy <!cnighp«] occaHioujiLy, but tlic pf ya- 
jcitl »i<^u8 about LiH difst were nomuU. HiH tompcmtiire on the lirst 
CfMiiti^; wuH 101.4°. mid coutiuiiod la stuuil nt much tbt- same levol for 
Home time. It suiuetiiheti amik lu i)D° and at other limeH roiie suddenly 
fcr a few hours to 101 , but it usually varied between 100'^' and 101 . The 
boy continued iu nuidi the ttanie atate, beiui,' usually apathetic and dull, 
altbough he bh^ht«n«d tip a little at tuues uud would jilay listle^Kly with 
his toya. The eourse of Itie Jllue^ wiw very variable, mid the child seenied 
much worse at some'timca than at oUiei-s. Once or twice he HSenied 
decidedly lietter and rt't^iiiiK^d a few ounces of hia weight, then he relapned 
and WTuited, rapidly loain;^' a pound nncl a half in a wook. Often bo was 
drowBj", and hia i^i^pctite was always poor. 

A» tiroe wont on the Uvt-r and spleen became modfnit(.'ly awollon. aigne 
of eulargement of the bronchial gUnds were noticed, and deep pres- 
mrc in the abdomen discovered some enlargement of the mosenterio 

The ImwcIh reainiue<l more or less looHe. Ttie boy grew slowly weaker, 
sod dii'iJ after a resiileuee uf four uioutliH aud a half ill the hospital. 
There was never any i^donia of the limbs, and the glands iu the nook were 
not ofiecled. 

Od examination of tji« Ixidy after death, large yellow, cbocu^'-looking 
masMta wt-re fonn<l ndhorntit tn the iinilor siirfnce of the breast-bone, and 
the anterior lutdiustinuni was tilled with n large moss of agglutinated 
glaufla. A siiriihu' iiuiss was found in the abdomen in front of the spine 

iuflt below the diiipbragm ftiid aiuTounding llio iieaii of the panerens. The 
iTCr was large, soft, and Ihibby to the touch. Its Hection showed a half 
tcmualuceut appL-araiice, aud on close inspection this was found to be due 
to a multitude of closely sot little masses, the size nf n pin's head or less, 
some clear and traiuitxu^ul, others wore yellow. The spleen also wu» 
I'lArffe, nod it^ section showed tiw appoaronco usually noticed in this disease 
^•nd which has been alreiuly deaeribed. Both lungs were found on sei'tiun 
ito be pervaded witjj anmll ruiwaes of new ailonoid gron-th. 

Iq this case the (general t^yinptoiu-tprect^ded tlio signs of local iniBcliief. 
Often, however, especially if thf illness begins, na it. coniiaonly does, with 
^ •nlargemont of the crerrical gLiiids, the alfectiou hau at fintt the rhnractcrs 
lCl ■ loeol dUoose. But sooner or later, as the lymphatic Usiiue becomat 



more na<\ more involved, the patient begius to Buffer from irrej^^ar f«T«r 
nnJ ^rutvM wry decidedly aiuei»i& 

liie '(LiiitluliirsivelliDgs in the ii«c1e uKiinUje form nii im'^iikr nodular 
mass whicli miiy extead from one side to tlootlitr, pMtnug uudfrat-Htli the 
eliiu, or may be limited piiucipally to onv side. At first the iudividuiU 
gtonda cat] be niiide out, and tho iimoscH are moTable. Afterwantstke gL-iu<.Ls 
beoMine more weMed toj^ethor and Uiemniwesare t\cd. Tho swellings ure 
puiuleae, and unless of v^'Tt rnpid Rron-Ui iiro dcin«« nnd firm to Ibe toucli. 
Id some cases a insim ofcnlai'^odi^lruida will bnc^oiuc verj~ aoft iukI nuppu* 
iRte, forming an nh«cesH wliich diHclmrges and liealfl up in tlie ordiiiaiv 
tonmier. Uesidcs tbe uedc, «ii)arged gumds mny \» frtlt in the nxilbp aod 
groins. In the Arni[)ita Uie az/o of tliu fp-on*tli« may interfere witb Ibe 
movements of tlie nrma Examination of tie chest and Ih-'IIj often di»- 
cnviirs n similar ehungc in tlie glands tying in tJie anterior meiliaKtimim 
and ubdomcn, Tbe eiiliu-jj^cmenl of tbe bver luid eplccu lit uuuaUy uod- 
emte, althnupb winiLtiuies — capL-ciiilly iu tbe com of thw lattur organ — it 
ta'.iy lip Tfery poiiHulcruble, 

Wliilc tbe diswase is limited to swellinK of a few glands in the ne^^k, 
tbe cbib], oltliuugb yaic, may be active and cheerful, (ijipat^ently &uffi-hug 
ID no way esctpt from tbe local incouvpnience. Wieu. bowt-ver. tbe 
glands grow rapidly, or tlie disitoao (<iircai.l» finui the neck t« utlicr |>art8 
of tbe body, conslitutioQal symptomv b^giu to be noticed, l-'ever is olmoat 
invariably pi-cst-nt, rdtlioiigU in the earlier stage it is aligbt and inteniiittent. 
Id tbe cuL-beetic; utago the teiiiiM'i-alure often riROs to a liigb level, and 
for a few davs together mny rauKO between 103° and 105°, scaoetiiOM even, 
pntotiiig tlie higher Umit. Sweating; is t\oi couimoa ; imleod, in moatcaara' 
the likiu is cxcextdvely hnnib and dry. Tlie digestive organs almost inva- 
riftlily Buffer. The tongue is covered with a while fur, and the pnpillfl- arc 
proiiiineiit and red. Ulcenitivu stoiuntitiit mny be preiieal un th» iutitx 
ado of the cbeet. The ]ip])etite is poor and iudi;'cat ioit and voiiiilinK mny 
be oomplaiued of. The howela are sometimes costive, but often Ibey 
are looee, and the dejectlontf mny he preceded by griping pains iu tho 
belly. Tito luuHt-ijeiut is ilite in many imsea to small ulcenitiouit of the ileum. 
Tliere in then ustially ubdoniiual sweLliiig, iuorenMed tension of the parie- 
ties, and tenderness on pressui-e. More or Use cough is a common ^m^ 
torn, and an examination of tbe ehest often iliscovere signs of eonsoUiW 
tion and Hofteiiing. Tliese lesions eonuuoiily result from growtbs in tbe 
luLg whieb «ofl«u and break down into cdvitice. 

Great auathy and dulucDs of mind are in miuiy caaea aaaociated with 
tlie cacbertic Rtage of the diseaaa The child may be fonnd to sleep almost 
confllaiitly, his senses seem dtilled, and his wants are bo little pressing 
that bo Aska for nothing and makes no coiiiplnint. Indeed, sometimes it Is 
most diffieiilt to Ret hini to spenk at all. The urinary function ia inrely 
interfered with, hut soinetinies lilooil i<i paused with tine urine. In a casa> 
re[tiii"tr'<! by Dr. ftooilhnrt — n liMlft girl ngwl ten montbu — tho child's wnler' 
towards tho end of the di»c]UH; bcconic rc^l with hlooth 

The UDipmia is nmifiUy estrerae. The whole surface of the body is ex- 
cessively pale, and the mncotia membranes are idngularly bloodless. PuP' 
purie i4)>otH mny Im^ fouixl on tbe body, face, and Unibe, aud eomotiincs 
Urgor <lark purplixh blotches are »i*en from more extended eitmrMaiion. 
Flushing of tbe face is n commou symptom, and a redness of the cheeks nt 
this time forms a curious contrast witb tbe dead whiteness persistaDg round 
the mouth and eyett. A mirmscxipic examinalton of the blood shows (he 
diminiitioD in the number of tlie red oorpusdee which has been ah~enilj 

rsfenr«i1 lo. The wliite coi^raAcIvs are rorelvin notable oxceae. As a con* 
Hequeuce of tlie luiirniia <cdcnia coat occur iti the limba, anrl tliere nuy be 
R8Clte& Prcsmm of the enlarged gbtmlH ii]>on tiw vcnoii.i tninks lany also 
aid in tho pivdoction of wroua efTiiKion. 

A ffood cxAiapIc of tho more ei^niiuon form of tho diaoMo, where the 
geopml constitutioDal (Usturbftncc occurs Bubw^queiitly to Uio pritniiry 
glandnlnr enlftrgetiient. was seen in tlie case of a litUe Uov, aged tbirli»en 
rwun, who was undM tlifi parfl of ray colleaj^ir. Dr. Donkin, in tli-* VmA 
Lonilon Cijildn-nVi Huiipilul. The bov cittiiu of ii liciilUi; family aiiil Itiul 
himself been strong and healtliy until Ihe age of eight years, when he was 
hiid up for three tnonthe in consequence of a fnll on hii head and i(]>in(t. 
la this ilIiic9S the 1a<I could uot rest ou his lm«k or »idc, but tviu) obligt-d to 
tie ou liis face. Although he began to walk again in two moutbs' time, and 
vias i-oiivaie«ceut itt tlie end of the third month, he never recovered hitt 
Btrength completely. Tn-elre inonthe after hie illness lie was again laid 
up wiUi pains iii tlie chest and swelling of the face and aniiti. Tli« Rwell- 
ing soon xiibttiilvd. but the boy reiiiaineil weak aud complainiDg and waa 
often under meditiU ti-eafmenl. 

On adniiiMinn the patient complained of lumpa in his neck wliich he 
8tat«»d"Wftre of tlu'fre yeniV duration. For three months he had been losing 
flesh and lii»* belly hiul been gi'owing birger. Hh ^kin, he liaid, )iad Wen 
drr forsomo time. His IcgH bad ncYc-r swcUod, but ha lin^ noticed a bwqU- 
ing of his Bcrotum for tltrce or four days. He waa mihjcrt to rrnmp-like 
painM about the umbilicus which were often severe, ami the belly at thene 
times was tender. Hi: had had a cough for a month without exJM^cto^fttion, 
BUd luH bowuU hml buvu rclmed for a week. 

Ou examination tlie buy was found to tie very thin, Hud bis xkin vras 
drv, rougli, and fm-furaceoua, especially about the belly. Tlie cenical and 
8ub«aaxulai7' gloudft were enlarKt--^ on both ddee eo as to form a collar 
round the neck. Tbe niHlitry and inguinal glands were normal. No en- 
largemflDt of tbe liver or Kpleeii wilh nutieed. The aMoraen wae distended, 
with fulneeo of the superficial veina. There was some tecdemefts on 
presHure l>elaw the umbilicus, and the tension of the paricties was in- 
rreaaed. No growth could lie felt in the I«dly, mid there was at no 
a»eitoiL There was Bomo a«}ema of tb* ncrotnm, but iioni' nf ihe anuK or 
legs. Tho tongue waa I'cd and rather raw-looking, and »omc Huperfici^d 
ulceration wa.s noticed at the angles of the mouth and inside the left 
eheek. Tho IkuvkU were relaxed, the stools being loose and lightish yel- 
low in colour. There wuru »igii» of coiiBolidntion of the right luug. Tiid 
urine van pide. Hli^htly alknliuo, but contained- no nlbuiucu. An examiii- 
ttiun of the bluoi) showed the absence of any excess of white corpuM'leit. 

After admission the boy remaiue<l in a very apnthetio state, and whether 
up or in bed aoeiued to l>e always droway. He would be found asleep 
with Ills be:ul on lib arms or curled up on a sofa. Hia face was habitually 
very pale, but at tiiuex it would flush up irregularly. He coughed oeea- 
nonally, and expectorated tenacious mucua His temperature was nlwaj'S. 
lugh. rising at night to 10:J''orl04 . He continued to waate and grow 
weaker. Death was hastened Uy a severe attack of voiuitiDg which pro- 
duced great prostrntion. and he died soon afterwards, 

AftCT death the cemcal, bronchial, retro-peritoneal, and rnesenterio 
glands were found to be enormou^ eoLirged. forming agg1'>nierntvd 
majBieR in which, however, indi^idual guuids eould sttll be made out. Tlie 
enlargc^l ^^Uuda wore Torr tough. On ttectioa, the larger nundicr wcr<-' of 
yellowish tuit and aeemea fibrous, but a few were grayiah and IninslucoBt, 



Some ooiitAitiM camoiu niattor. N«n p'owtlis very RimUtu* in ftppeartnce i 
were found in Ujc pleura mid peritniicum. TIiltc wore imjiuo ulcere in tJie 
iliuns aiid etpomn. Tlie foUicleH cif the tungut wei-e NWoUeti. Both tonitibi 
v/i'Tc ki-ge auil ulcerated. Small uloers were found on the anterior wnll of 
{he travhua ; nnd od tbc posterior 8urf»c« of the epij^lottiit were yellowish 
iuHIlnitious of «L roundish sliupc. All tlio niucoiut iiKtuihranc iu this ueigh- 
Imirhood was liighly injected. Both luugs were Uie eeut of conmlidutioa 
which had broken do^m into cantico. 'Ihe spleen was Itage, aoft, uid ooo- 
geittetl. The Mnlpi^hiuu tufid wei-e not Yisible. The kidneys iind liver 
werv iionuAl. The uimrow of Iho right fomur wiw mottled, red, aud gmy. 

The irrvijtiiai' or accidental ^nnptoms arise teom presaure eet up hy 
enhu'ged glands or orfxans upon a^ljocent partfli ThuH the Awnllen ghoids- 
in the Dsek may prem niM>n the jugulnr reiiiii, and b,v imjtediDg the « 
cape of blood from the i»ti>rior nf the itkuU, causo liaavinMB, drown- 
noEB, cedema of the head oud neck, and cpistosifi. Thej may ^ao liam* 
per the raoveincntit of the lower jaw, press the Inrriix and tncbea to 
one fu<ln, nnd tmiuie d^npntDA by theii' interfeivuco nitli the air-posMgeo. 
KometinioR tlic-y nhsitruct the rhnnnel of tlie gullet i^o tbnt fooii passes ^ith 
diiUcuIty or Hwallowing bcconii^ actually impinttublc. Enlargement of tba 
brotichial glands nniy produce dysputea, apiuiiuodic cough, nnd all tba 
symptoms which have been enumerated elBewhei'e aa the consequcoeo of 
preaaure within the cheat (aee page 181). Growths of the loeticntcrio 
glaudii may set up luwiteu aud jaimdice by their pre»mre on the bile-ducta 
or portjd veui, tuid (edeiua of the scrotum aud lower limlM by their inter- 
ference with the return of blood through the inferior reua cava. 

Pandysis has been occasionally noticed. TlinsDr.OfKxIluirt has reported 
the caao of n little l)oy, «ged sii, who was ftdniitted a imtieut under Dr. 
Piwy, ill Guy'*Ho8|iitAl, for complete pamplogta, witJi ineontinenc« of urine 
aud ilefiriency of Hcntutttoti l>elow the umbilicue. After death a lympho- 
matoiiH gi-nwtli was found in the thomx, whic-b had entered tbe apinal 
eaniil in tho dorBfil wgian by [maning through the iut^ri'ert/ltral fomiuiDO. 
Here it hud lined th« Ituniuit- of the verlcbnij from thu luda to the 
eighth ccnical segments lo addition it biul formed a mass which at one 
]K)Lnt completely filled the canal, cumpreHsed the. cord, aud had fonuod 
adlK-aii^us with tlie cord aud the dura mater. Below this point the sub- 
anK-hiiuid fittRue was distt^nded with fluid. 

In a case which wa« uuder tny owu vtatt in the 'Eaai Loudon Children 'a 
Hospital — a boy ten yeaTH old, who sufToi-od from an euormoiis mass of 
enlarged eerncal glanda on the right side of the neck, beaides lesaer en- 
largement of the menenieric and inguinal glands — for some weeks be- 
fore the child'a death ptonig waa notioed of the right eyelid, nnd on esam- 
ination it wui foiuKl that the pupil of that eye was eomewhat dilated, 
and that there woa paralysis of the iut^.-rnul rectusi. At times, too, the boy 
oomphiined of severe neuralgic pains iu the right eyeball. After death, 
inapoetioD of the body ahowed a ninRR the size of a walnut, which lAy in 
tlie middle ccrobnd fosisii, uud wus adherent to thc! dura mater corering the 
CBTemoiiH sinus. The mans bad a prolongation which passed tlirouch. 
f,he foi-amen lacerum medium and joined the general glitndular maiw in 
the neck. It« pressure upou the right third nenra had cauBed soma 
ulrophy of the nerro — for it watt appredably thinner than that on the Wi 
side — and had, no doubt, given rise to the paralytic aymptoms which had 
been notLoed duriug life. 

The <bimtii>n of a caae of lymphadenoma is Teiy rnriaUe. When the 
illness begins im a local disease, thv course is usually rei/ tdow at the iit^t. 



Btid it may be rearfl before iJio gAncrnl gUinduIar ii78t«m becomes ftffectecl. 
Wbca. liowerer, Ui6 cacliectic uta^o be^^s, the course ib more acute. 
Still, the progTi'sa of tlm miUody ia alwaja vnriabic, mid prowtli is more 
mpiil at m>u:h> timea than at otlierB. In tlic chilil tha gc-nernl di>«aw i 
rarely ianta longer tluui nix op eight imintlui. DontJi nmy reicult from lutttM-' 
niA or from some iwinpliaitinij, aa ptieuniouLii, pleuriHv. vDinitiug, or diai^j 
rbcaa. It may b« i>»-c«^lei1 by coiivuli^iuiix. SumetiuiLoi the «i)d in liat^ < 
t«Detl hy thu iiijuri'.iiix etTeols of tofucluuiit^fil jireiisure upon the air-paBRages, 
the Kullet, or the Inrge veina of tho abdomen. 

iiia^Qxi*. — In the diagnosis of n r-ase of Iv-mpItsilcDoniM we tiave to 
search for eTid<>nce of goiiprtil iitl«rtioii of the ^landidiir B^-slem. So 
long at the discjise reraaiiia liniiwd to n few glaiidB of tbe nock the nnture 
of the swcllinR ia not alwiivx easT to nHrerttin ; hut even at tliin time it 
may he RometiiueK dixtiiiguiRhed bjr tlif ela^tii^ity nf tlio f^n-tli, for, luv 
noming to BinOi-Hira^hfclil, even in th« liiirdi:*r varinty of Irmphiul«notaa 
there 18 n CL-rLaiii eluitticity lui c(>mpiux;d with thv UitDKc, lN>nrd1ike hard- 
nctw of the (.-heeay gland. Moreover, there ih no inl^nmniiitton set np 
round the matts, and caaeouB degeneration and softening are rery rare. 
In A group of scrofuloua glands Aome uflilally soften osriy and fona ad ab- 
scess. In such a avtv. Uk>, tbe general nigiiK of «rrufiiln luuy be uotioed. 

fiftrcomatoui* gluiidM pri'«eiit n grtta.U<r likeueits tu lynipliadcnomu ; but 
trlieij exteiKiou tnkoH placo iu tbe former diueoMf tbe tiuHiit's involved are 
ooi especially the lymphatic tissues ; indeed, tho disease tends to spread 
rather to organs tlmii to glands. 

In tliR cneboetic Riago lynipbmlennmn in iiKimlly ontiy of n^eoguition. 
The irrofitiiliu' fever, the extreme pijlor, the groat ilrowsine^s and iiritril)- 
mgDBss to spesk. tlie general iniplicalioii of lympliatie glands in all paita 
of the body, the character of the blood, nhich ahows diminution iu tiie 
number of red eorjiusdea with no or only alight inereaae in tho proportion 
of leucocytes. T1k-«(; 8yijiptt.iuiH and ftuflicieiiUy chanictehatic 

Proipimt!'. — Although some cnaea of recovery from thin diiseiute linve 
been reourded, tlie ilhiess in hu generally fatal that little (lope of a fiiToiir- 
able issue am be entertained. In the cocheetic stage speedy <leath may 
be anticipate!. Iu the earlier periofi a prolonged course n»ay Ih? hoped 
for. P8{)eeially if the eDlarg«meiit is slow ; but it is iinwifH) to speak Iw 
favourably even of this prosp&ct, for tho diseAfle mjiy at any time nuddenly 
BSKume an acuter riharacter, and variations in the rapidity of its progivaa 
ara oot luieommon. I^icainination of the blood may he of some Kervice in 
wrtimnting tho pmhnhilities of a longthcnrd cnuriir. If the nuiiitM^r of red 
corpuM^los is grtjatly reduced, the child's jirospcctB arc \cry unfavouruble. 

TVeatijiKiit. — In every case the child shoiUd be put hito as good sanitary 
eondiUonH as powiible. and eveiT effort shonld lie mode to improve the 
genenU health. Coddivcr oil, iron, quinine, and tonics genemJly are use- 
ful iu this rw<])eet, but none of tlicsL- remcdiL-s have the jxiwer of dftliiyiug 
materially the prugretu of ttie diseasa after the afleotion of the lyniphntio 
glands baa Ijeeoma general Arsenie, howevM-, ia higblv spoken of for its 
value, even in this stage of the dL<iense. The' dose should he n large one ; 
and it must l)e reuK-mbered that most children have a special tolerance for 
this drug, being often able to take it in birger qiuuitilies tlian ean be 
roadOy borne by the adult For ft child of eight years old ten drops of 
Fowler's solution may be given three times a day, freely diluted, directly 
after food, and every few days the dose can be increased by two <hv| 
Tbe affect of tho tQ»diciiic is to increase tbe softii^ss and mobility of 
gluido. Soon psin begins io be cuiupluiuod of iu the HwuUiugs, and 


is quickly followed by nn ftireat iii Uicir gronrtli. or orou uu apprtcuible 
diniiiiiitiou in their auw. Iroii mny bo friveu with llie attteuic if thought 
(.{(.■nil-able, aixi tlie coiubiD*tion is pr?f6rr(><l by some. Pho^honis luis 
beeu iiko recoiatuended bb useful in nromotinj^ rediictioQ ia size of the 
gkOiU ; but tJiigib-ug appears tn l>e (leridedly infei-ior to aiseuic Icxitde 
of potaeeium has b<!en foimd quite ii>ielc»iti as an nbaorbciit io tbis discaae. 

If the palaeot come under ubitcrratiou wb«n the- Klanduhir swelling is 
limited to the npck. sntl the general system appeom to he imatftetod. we 
may be^in the ti'mitiTicut with greater bopen of miccensi. 'Eorlj extirpati<Hi 
of thr growths i» often odTOcatcd, ood the operation is said to h&ve ]>c«-n 
followed in some raiHcs by complete rtcoreij-. E«cn if this h«ppy resuU 
be not nttaineil, we nmy expect tliiil in it suitalile case the prof(rpi« of the 
diSMtftc will l)c sf-nribly (checked by tlio opemtioii- \\'e win, howcTor, only 
niiticipntc ;^ck1 rt-tniltM wiii?u the (,'htudiiLu- (-iiliirgt-uieiit in limited strictly 
to one group of gUmlK, the Bpleen is uimftVctod, and the priipurtioa of rwl 
cfirjiusRleB in the hlood ia not grentlv reduced. Dr. Gowern recoinnivnd« 
tbut ill cwry ctutc llio notuiU proportion of red oorpu&cles be eatimatc-d hj 
the lueuiivrytuiueU-r, luiil ttUitea tlinl if the proportion of coloured cells be 
lesn tlinn aixty per cent, of the' uomial nvomge. tJie idea of opemting 
HhooliL be abandoned. On the other band, a eliftht inciease in toe quan- 
tity of wliit« cori>uscle8 is not to be considered prejudiciid to the succewi 
of tlio opiftntiou. After remoral of the avollen |:lHitdit the clidd should be 
sent to ft bracin<; seaside ftir, and arsflnie with quinine or iron should be 
given in full doses. 

Accoriiinjj to some writeiK friction of the prowing glandti witli tlio 
baud alone or with Home Himple salvo has been found useful, nnd coiti- 
pn'ssion luid blit<ti>i'iu(<; have hi'va also Kcotnm^nded. Injcctiuuti into the 
gliinds of viuiouM HuJistaucL'ti, such an iodlue, carbolic ncid. etc, is not a 
safe method of treatment In one cnse iu which I injected tiuct. iodi into 
a hu*f^ lyiii]>homatons swelliug the operation was followed in a few days 
by a rapid uud penuaneut increaae in tbe size of tiie tumour. 



DnxRjoR.vTio?* in the qnality of the blood, (<oin1>iDf>4l often with tleficiency 
in itA (juiuititT, is a romnion I'PKiitt in infanry fuiil c)>il<lhooil of nny con- 
tUtiriu wiiicli cfiiiBna a U'nijioriin' failui'n in tlio milritiTo proootwes. In ths 
cLild aufliinin U cotumouh' r<ymptomaUa uf »umc diiitrovtimUt.- iU : for tlie 
obscnrer form, railed idioi«nlUic or pemiciuus ontriuiu in the adult, is but 
ruelv iiiL't witli ill varly Lifu. 

The reoHOD of the exceptional frequency of impoveri^meat of the 
blood in childbood h not difncult of explauatiou. From the re^enrches of 
Denis, Po{f^iiU«, Wiskouiomi, uud otUura it upjwiini that iu infancy &l- 
though tho quuntity of blood in ^pvat^r tban it in in nuitiirer Ufe, in pro])or- 
tiou to the entire weight of the body, tliin l>loo«l is of lower c^cjfic ttravityt 
and contaiim more wliite coqinwiles, but lesH Abriue and soluble albumen, 
a ftmiller proportion of aiilts, and n coiisttdpmbly smaller qiinulity of lintiio- 
glnbiii,' Wilii this ooiniiftrativoly dilute- blood the frrowinj; child hft» to 
undertake n lar^ji-r work than i« reqmred from the nnult. He hna to sap- 
ply mnterial for growth and development instead of meroly maintaining 
the necessary nutrition of tiHHuefi nnri orf^ans already matured. The heart 
unl luajj;!! are forced to (,'rcat(.-r utTortH iu answer llie tk-iuii.ud» madtt upon 
them : tfio fintt to drive n Hn(lii:i«ut (jmuitity of blood along the relativelj 
wider arU^riul chmintiLf ; Um ueeuml lo ai'mtu the larger proportion of blooa 
carried to them by the more capacious pulmonarj- arteiT. The lun}^ elimi- 
nate carbonic acid in far hightsr propni-tion than is the case in older per- 
iwiu. The amount of uroa, too, oxcccted by the kidneys is rolntively mueh 
greater than it in in tha adult. The work ri>qiiired from tlio diflferont «c- 
cretory and excretoir nrjicanM whoae united labours po to build up tbo 
growtnt; frame may be judged from the &ct that nilliin twelve months ot 
itf4 birth the liody linH incj^aaed to three times ibs original weight As l>r. 
Jacoby has ob^R^rved, thu "orgnnx are in coutftaul exertion, or rather over- 
cicrlion. and all this nt Diu cxiK'Hiu.- of » blood wtucb coiituinH Ifxet solid 
count itueutii than the blood of the old. Thua the natural o)igR>mia of thn 
child is in constant tlaager of increasinfr from nomuil physiolocicai pro- 
OMsee. 'Pile uligiitait mishap iT'rhiw.H the <-(|uilibrtum l>etwci>u trie capitnl 
kml the labour lo be pei'fi>rmL>d, luid the cliiinceM for the dimiuutioii in the 
amount of blood iu p-inneaaion of the child ara reri* fr(>(]uent indeed. " 

Although the blood of the child in thus rebitively poor fta compared 
with that of the adult, a i.-ou»tiiut inflow of nutrieut inaterinl enables it to 
prpwrro n lioidthy utnndiird and carry on it» fuuctioue with succcks. Tlin 

' Hw>iiw((lol>lii ta llio clii«f Ronilitaoat of tbo ttsd oorpnwliw. In Um noirljr bom 
Infant IU tnioanl 1* roluiTAly lu^r than ft t* iti tli« udiilt, rnacliinft tlia iii^h rnllon of 
3^ •£ [mt ffoat. of the wholo solid GonBlitii«nU [at ailiilt ura il ia niilv l».9U jht miiL). 
This tiigli peminUiCc raiildl^ dtulnhliM until U ruaoliw 1I10 lowoat point it tlio ago v 
aix monlluL It theu iluwlj? riM« t^tiu. 



ainoiutfc of food consumer] bj tlio j^i-owiii^ oliild is fnr greatfr proportion- 
alcly tbiui that retjuired by tbo full; (U'TcIo])C'J mau. Acrortling to Dr. 
tklward Smith, Llie infant an cninparetl vntii the ftiliilt cx>nsunies three 
tiiaoH as niticti carboii riu> tux Umfs ils mii<^h iiitro)^rii for cvorr [Kniud of 
liis wciphf. If now, from any caii*o, «itlicr from iIetioiitn<'j in Ui« tnipply 
of food, or (ierangrmoiit of tlic ruachinery by wliir.b foo<l is elaborated ana 
preporod for Hn purpose of noiiriHliing' and reneuiiig the tiwniGR the ioQcnr 
foiU, the RtaDdard of t]ir- blood nt once «iiiks bolnw thp average of heait' 
and n Htate of Mnemiii or uli^-iaiu (T>Dom(.-i«i of blood) in induced. 

The consUtucuta of tbi- bloo<l wliicli aro of the grealcsi itiipoi-tance in ' 
nutritiou m-e the albuminoid comjioiuidH of tlie p]Biimu aiid tlie i*d bl<t<Ml 
corpusclCB. Xhe albumiiioid eouipounds fonstitute the material ont of 
which tlte tiiwuee are tioiirishrtl ; ittie bie-tnoglobiti of tlie red nHpiutrles 
caniifK the oxy^tfn, without which tht* clteiiiical changes QeoMBarr for nu- 
trition ar« impossible. In flnii-niia the blo'td is impoverished it) it« albn-* 
minoiia cnn»litueiils, e^tjx'rially in its hiomuglobui. Therefore, as tha 
amount of iron in in <lii-«ct propoi-t.ion to tlie amount of htriiioglobin, a 
<liniiniiIioii in tho Inttor nunuiM n, tWUcipncy in the fonnpr ; and lui the i-biof 
office of tho bfcmoglobiu is tbett of convi-ying oxy^-u lu the tiisiues, tho 
blood in anamua in no longer ublo effidcnUy to purfunn itH reapiratory and 
nutritix'e funntions. 

Vaifation. — In eai-Iy life any causte which interferes with the orderly 
renewal of the normal couHlitut-nbt of the IjIooi] lunds to aniemia. In the 
iufiiut — a being irho iM dependent fur hMilth upou ii full daQy aupply of 
food — not only nerious duease but even the most simple ac^ute derangt 
ment will leave Uie bloo<l io a state of ttmporary oLigieimit. Thia 
itinially rapidly reciiverwl from, for in t,h* healthy child oonraleacence 
short, and the nutritive functions quielily rpHuitie tJielr course when th«1 
obstacle to their pro|>er exercise has disappeared. By aoa'mia, however, 
is ufluaUr meant a more prolonged pnomci>» of the blood~a condition in 
which the symptoms of general ileliility are allied with otbera indicating 
an imperfoot perfonnanoe of the bodily funotiotts. 

Tlie causes of such a condition iitiiy be diWded into tvo classes, accord- 
ing as to whether they interfere with the eoutiuued renovation of the blood 
or abnormally increase ita consumption. 

In the first class are included all the varioos conditions wbi^ hinder 
tto introduetinn and eJabomtion of nutritive material. Thufl. actual defi- 
ciency of food, 8uch as arises from e.rtrem« poverty or wilful neglect ; an 
unsuitable diet, the uttomneh being loiuled wiUi fm>i1 wliicfa, from its nature 
or form, is Itcyond'the child's power of digestion ; functional derangementVjj 
of the Kastro-intefrtinal canal owing to which an otherwise auitable foodT 
JR rendered temporarily inappropriate — these causes may pi-evsil nt all 
periods of childhood, but are e8]>ecifdly frequent during tiio period of 
infimcy : and the uun-mia and waMiug which ai-o »o common in iiand-fed 
babies am usually 1>g refei-red to U»e action of thrae agencies. To tliem 
must be added the influence of imperfect ventilation. Oxygen is na csseo- 
tial to lioidthy tissue cbiinge as are the elcntenta of food Uiemselvcs, and in 
its absence tlie chemical <?hangefl ueceKsar^' for the renews! and develop 
mcnt of the tisHues are imposmble. Couse^iueutly infants conlined to 
cIottc>, til- ventilated rooms are jiale and dabby, however ciureEuUy Iheir 
dietary may be atljusted. 

The above eauseg ore also powerful to impede nutrition and promotAj 
the impoverishment of the blood after the period of infancy hsa gone by. 
The inlluence of digestive derangements, combined or not with wsnt of 




fnHili air an<l exemw, in onft of the rommonwt cntDtes of nniraua in later 
chiUlluvnl The cnuaea whicli intliioo iinpovtri«hraonl of tli* blooci are no 
doubt oftvu coniplfx ; but of sucli as act nlone imperfect digestion from 
catarrh of llic kUhobcIi ia perhaps to be bkmetl more oftea Uiui any other 
injiirioiis oondition. Ttiese littAckfl t«iKl to ba roi>ent«(l, and, tu» ta else- 
where eipbine*!. re<?urriLB goatric caUirrh lUftr iinlnce a dcproe of piJlor 
anil wiwtiujj which excites tlsc p'satcKt nlann iii the mind** of the p^rcntA, 
and often requireti vet^' careful treatment for its prevention and euro (net* 
Ciiutrie Catarrh). 

A^ii, the diathetic diaeeaes— tiibenruloRis, »crofu]», mid avphilitt — 
o(t«u uiduc« a decree of aowonia, eveu before auv load mituifpHtittionii of 
the euustituliontd <li8poaitioQ are diacoTemble. In syphilid, uIhu, the dia- 
eose, after opporeat recovery, is apt to leave behind it » state of urofouud 
anflania, whicu in mnnj caseft in to be attributed, uot to the maliuly, but to 
the iDodicntJoi) to which tJie pntiont Iias hwn sultjected : for n proluu^ed 
course of mercury ia an uurailiup canso of impovorisbment of tee bl(X>d. 
In ricketa, tJie beginning of the iltBCOSo is nnnonneed, and itM progreas 
nrcompAnied, bj a marlL'ed degree of aniemin, whirh indicates the unfit- 
new of the blood in suph n caRe to fulfil nil tlia n>qiiiren)onta of healthy 
uutritioo. Of other spttijil fjcueral diHCMffs which mny lca«I to diminution 
iu the amoiuib of hiemoglobiu iind a<3 Het up amemia inaj- 1ie mentioned 
rbenmatiBm, acurrj, and the cachentir; condition indueed bj miUaria. 

IKaeoae of special org&us concerned iu saugtiilicatiou the Hpk-cn, the 
lympliatiu aTsU-m, t-tc— is. of oourftL'. fdliowcd by great idbemtion in the 
qn:itily of the blood. Iti extenMve aiujloid degeneration of t)iet<e orgnnti, 
tiie marke<l pallor of the patient is one of tlie nmat tttriking avmptoms of 
the diseaae ; and in lyinphndenoma the patient is jiecuUurfy pale and 

TiiB causefl vhieh im^rcaao the eonaii nipt ion of tbo blood are : Profuse 
hmnorrhagea, as in mehuna nconiLtorum, hicmophiliit ftnd h.'i-morrhagic 
purpura ; severe diarrham ; chronic purulent duicbargea, an in canes of 
oluonic etapycma with a ddtulnuH opening in the oheHt^wnU ; cirrhona of 
luDg nith 'dilatation of bronchi; albuminuria; onaniiim ; etc. In thia 
rliMii, tnn. most bo included rupid growth, which is a very frequent boutcc 
of languor and anaania. It inuat be rvmembered, however, that at the 
1^ when gniwtli ia apt to be most rapid the child ia oftpn es^josed to 
otbor iiillufiKX':! vrhiirh may also tend to set up iiui>civeri»huK'nt of Uie 
blood, njifh IU couliiirnieDt to close rooms and want of exerciso. 

Idiopntliic HiiRiuiii (which ia Bometimoe seen bi youug people) tnay re- 
mit frpiu bfttl and ineumcient footi or other depreosing ctiuse acting upon 
ilia guoenl ayslem ; sometimes it is the oouseqnenre of nienital shock, aa in 
the ease of a bov who was under the care of Sir "Williawi OuU, iii Out's 
HoepiUd. The lad began to suffer shortly after being attacked by a num- 
ber of sheep in a field. 

Mnriuit Aiutlomy. — In nnwmia the blood may be merdy deficient in 
amount (olif>n-mia), but it ih uBuall^ found that there ia also a defieienry in 
the lucmoclobin (ag:l<ibaloaiB). It ts not often that ootunl iliminution in the 
□timlier of the reil coqwisrlpa ocrura in onlinary ^mptomatic anaiima un- 
tam, indeeit, the impovondliment result from wvere hn-morrhage : but 
tbece bodies are Baid to bo coiisidcmhly rpduced in mtA, and in certain 
forms of nntemia it is common to 6nd miuiy corpuiKclcs with n diamt^ter 
graaUy bcJow the average. The blood i« pider tlinn natural, for in con- 
eequence of the dcori-aftc in thfl hi'moplnbin it is deficient in iron. Ita 
^ecifie gravitj- ia ak<o lowur, and it coiiguljitee slowly into a looee clot. 




\n a reeult of the itnptrfiH-t Diitritiuu of tlio tixMioa which U tlie cod- 
Boqucncc of the (leteriorat^cl qtitililv of the circulnttnK tluul. n cl*'(»iy>o of 
futtv JcguiiL-rutiou may ha (ouiiil in the heart, tiic liver, tlic kiducva, luul 
even ill the n&Us uf tli« lilixnUvciMeU ; also in the Tolinitiu-v miutckH, auJ 
Ihe iflanda of the stomnch nnd iut<«tmes. 

lu idiopttlluc amcmift fatty clegeiieration of or^puis it tilM eomuooly 
obseniHi. Tlierc we. ntoreoTcr, e<xh_>Ti»iBes of seruiw uiirinbruiE^B. th* re- 
tina, ett'. Tba hlooil in not only d iniiiiiiUieil in (juantity, but ttie red 
blood corpuscles are also gKrttly roiluo*<l in number, beind. Recording to 
M. l/rjjine, one-fnurtli. one-Rixth. or ei-cn oue-tcuth uf tlit-ir uonnol pro- 
pcrtious. Tlio white rori>ii!u<Jes nre not more Quiuvrous thiin nnturiil, at 
ffiASt tb4>y ttre not iucrooscd to anything like the degree ol>ser^-ed in lea- 
khR^min. In some cases of pcnuciouH luia-niia miuiittt red corpuftclra buve 
bwn notirfltl raeiuniring only one-fourth of thi-ir tiutiirol nijaj, and niuituig 
the Ghara(<lonKtii^bi-eoQate shape. The«e bodieH, hutrever, appear not to 
be prtiticut in wvry caae. 

Si/myivmi^. — PooruetM of th« blood iiupliffl an imperfect state of tbo 
genera) nutritiou. This in wipeeijilly tht* wise iu young subjectK whoea 
blood, as hew heea ah-cady e^tplained, can only ciiny on its functions «ffi- 
cientl; on Uic oondition that it is contiuunlly reinforced by n regular iullow 
ot projK-i'ty elaborated nutritive mattrrinl. Cona^equenlly, in addition to a 
goiiiTtd imllor, the tnu8ck« of such subjects nre snudl and fliibby, their 
atrength is redured, auil theii- spirits may perhupa be depressed. Languor 
and indiii}x»Hitioii to exeri'isp nre not, however, euiistniit s^inpLonis of 
AQii'mia iu plitldhooil. BuyH suiTer iu thia reRpect niueb less tlinii girls, 
find when free from actual pain or diaconifort mich patienta are ofteu 
lively, und join mth aa much ahicrity in boisterous jjimu's as if they were 
perfectly welL Ltdeed, this cheerfiilneKs and iivtivity may in nome casM 
be an important aid to diof^nosis (ttec TuberculosLi) . 

Ttiu tiut of the skin urny bo u clttir, triuit«piu\-iit whitt'-ncsa. Often, 
hovrerer, it ia dull and jtsHty ; or may have h fiuut gief^iiish c-urt, sinuhir to 
the hue of chloroaiH, and the lower eyelid mny be livid aiid pui-pUsli. I'lie 
mucous niembrtuieii arc aleu> pallid. Coldneaa of the extremitieii is a 
Cuiiilinr feittun; of tliia L-ourlitiou. In oiiicinic Httle girls we are often told 
that the feet imd legs ore never winu, nnd the hands feel cold and rhimmy 
to the touch. Slight oedema is often met witli. It may affect the lowejr 
eyelid, but less commonly than in tlie atlidt. Usually it is noticed ill Ibe 
feet and ankles, aud if the anaemia be great, may involve also the luuuls 
and anna Iu niro coses thero may bo iriodemtc oMcites. 

Bn-uthl'essnoSiS ruid pulpitatiou on slight exertion sufficiently pronoiwced 
to cause distreHs are tint comiiton sii'mptomH of tuui^niiii in tlie rhild, but 
they are Hometiniei' piifwnt. The apjwtite ia often poor, diacomfort njay 
be complained of after fooil and the bo-ftt-ls ore ueuoily confined. As this 
ootiLlitiou of the blood is in miuiy cases a cousequciK^ of gtistiic derange 
ment. all ibe MMiij>li)mH hIucIi nre elsewhere enumerated under the head- 
ing of gastric catiu-rli aro often to be noticed. Flatulence, eapcciuUy, is a 
oonimou phcnomcuou. and fointneaa or actual syncope niRT occui' from 
pressure upwards against the livnrt of a fLuddenly distended colon. Ttie 
temperature in seldom elcratcd in ui xmcompUcatcd case of simple nnipntia. 
IV*^^>u imiy, however, be presemt aa a conaequciuse of the cause to mhich 
the impoveriiihmeut uf the blood is owing, or to aoone aodilentul compUc»> 
tioQ, such Bs t<»etbing. catarrh, etc. 

Children, the siibjoetti of oua-taio, are usually very nenons and excit- 
jible, and on examination of the cheat we often find the lieart acting vioh-ntlj. 



can ttotioe & strour; pulantion in tbe nocic, uid nith the hntirl plAC^vl upon 
the pneconiiiJ region ciin ft- pI a wt-ll-iuvkod Bydtolif tlirilL hn tbti noU'iico 
of the oanliAc notion 8ub«i(l68 tliv thrill c%aHe>i. ami the curutid pulmttions 
diiuinisb or diwippeiu-. Tiie imiukIb may then be heanl to be ill-Hccen> 
tuat«(], or perliApit miu-tuiuiBh. AItbciU|;L auitioiic canliuc mui-iiiunt an 
siitl to be HncommoD in young subjvc-tM. it iK not mre in caseti of pro* 
ncniiioed nuwiuut to doUict » murmur uUiub oeasen to ha lieiml tin tita 
pntient imiwovee. The murmur may be at the apex of the heart and is— 
sonietinien at least — ncconi[«Lnie(I bv ilutphicemeDt of tlie apex-twnt upwarcU 
ani) to t)ie left, ah if from clilalJitiou of the luft vvnlricle. hwac miirmititi 
are, how»T«r, thfr TDor« common phenomena. At tho base of tlte h«art tbe 
least pressure u|)on the pulninnary artery from eolarfed bronchial gUudu 
will give rise tn a louil »y»t()lic murmur in that T onno t. Ti) niiuty catuttt we 
can bear a venous hum in the jugulnr vein in tho Tiock, fuinictimoft, also, in 
tho loft innominatu vein, bulund the upper port of tlio Htcmuui. 

BU'tiUii}* from the nose nntl gumH is not rare in anemic cbilJrcn ; and 
in huspitfil piitieiitH pnleduH! ai'e eonimoii in tlie skin ah the result of flea- 
bitea. ItVain tliis oniioe tbe boilif-s of poor oliililrcn are oft4>.n ftpeclcled all 
ovt^r with httlu extruvutuiUoiia of blood. 

Pain ucToiui tbe forebetul, or somt^timeH at tbe book of tlie bead, is often 
complained of. In infants more aerioua symptoms mav he met with ns u 
oonsequence of ameniia of tlje bratu. The child lies witli a pale ahrunken 
face. Ayelida only partially dotted, and fonUmelle depretwed. His «xlreni> 
itiM feel ofdd, and & thE»rmomet«r in the rectum re^teni a t«mpomturo 
below the aoruml level. Soon tbe infant sinks into a etat« of semi-elupor, 
and anleas aroused by energetif: niiniulation will probably die. IrajKivei'- 
iahment of blond and protdxation 8o profound are apt to bo complieated by 
thrombosis of the cerebnil inniiaes or eollapflo of tho lunf*. 

The dunitioD of a onso of ordiuiirj" niniple anirmta ATiricH acrording to 
the measures which may be taken to remove Uie camw or cauaeK which aru 
impeding the supply of nntritivf material to llie blood. If the cauHe cJin 
be removed, and the child be aftvnvards fed with judgment and placed 
under Kood aanitarj' condition*, rocovwy usuiUly foUowu ver^- quickly. 

In viiopathic ami^mia all ttie preneding sjiuptoms mar be not«d. In 
tbitf fortD of tbe ^liJitease the anttmin is mure profound. The ekin is of the 
oulourof i\'or>- and the mucous niembnuieH seem perfectly bloodleaa. Optic 
Bftiititis may oi;cur n'ith ]iJt.'mc>rrhn;;e into the retina. lE^ialauii is common, 
and vomiting may be frequent and dintresHiug. The child becomes oxcM- 
aivelj feeble, anil Imo irregular attacks of jiyre^ia in wliich tlie temperutuM 
rises to 103* or 104^ Towards the end of the disease, however, elevation 
of tMupdrature eeouos to be noticed ; iiido<-d. tlir> l>o<li]j- lioni usually falln 
to a aubnomial level. Tbe blood hna the cUftiactenj aJready dosv-rilMid. 

DiagnOKU.—in every rnse of anjemia it in important witli regard to 
pmgnosia and treatiueut that we Hbould exclude KPrioutt organic and 
dtat lietie disonflc. Th« diagnottiB of the mnur onditiona whioh induce 
imporeriiihmmit of the blood ia treated of under their hctitkI hi;u<liugtt. 
It may be only state^l generally that if tbe cause lie elsewhere tlmn in some 
obvioua dcrangeroeDt of the digo»ition, wc ahould isHtituto very sciircliing 
inquiry into the family and special liiaton- of the patient, ])articularly with 
regard to dtatbelic tendencies, and should make careful esnminutlou of 
like Tmriouii organa 

Idiopathic nuicuiia may b« diittiuguiabed by the profound deterioration 
of tbe btfMMl without incrciit«e in the white corpuacU-s : the abitf nee of ilis- 
aorenble cauHe fur tbe pallor and weakueim ; and the attacks of irregular 


DiSGASB nr omLDKKir. 

jiyrfixta. LeiiMicj-tliemia is chwactcirised by increase in the proportion ot' 
wliiUi corpuscle*, ami lij enUrfjemeiit of the Hjileen or Ijonpliatir ^lauda. 

/Vof/KMW. — In BLQfomiit the pronioKis dnptnulB very much upon tbo 
■iriiuary diseue, if any auoh cau ov duouvcmd. If tbu poomuHe of blood 
b« tha xeqiipl of some prerious acute Ulnevu, or uUiei- cauHO wbicb hii& 
orasod to prevail, Uit> patient uniaUr reopoiids well to treatment ftml 
quietly recovers uaJtr ordinary n-titoraUv« OMMUrM. In owes of idio* 
putliic auBitnio, whoa the pniHtmtinD i:i sreut, tbo pallor extreme, and the 
temperatiire high, the ehild'a pnwpects are rerj* aufctvoumbie, 

TrMttwent. — Anrcmin must be treated according; to tlie cauM irtiioh 
luM produced it. Impoiml uutritiou iind ii pidlid fact- funu in UiemaelTes 
no necesiiary indication for th« employ meut of clalybeate r«mnliea. lie 
commonest rau&e of smemiB in tbe child, an bu already been stated, u 
gastro-intestinal derangement In uucb a case iron bas no power to im- 
proTe the conditio)) ci( llie blond until the hindrance tn digestion bus been 
rernoved. In luiitiuic infanta the diotitry must be roeoastructed upon the 
principlea recommended «laevherd (»i>0 InfBQtik Atrophy). In older 
children if, as often happens, the pntient be Hutforint; from repeated Attacks 
of gnatric catArrli more or leiu oevere, the digestive diiiturbanoo inust 
reooiro cArcfnl treatment, and measures niUKt lie ailoptc<l to leivieD the 
child's suHcc]>tibility to cluui{;:ce of temperature and to protect bis aensi- 
tive body from tlie cold ^moc (luxtric Catarrb). In nil ciuw-a plenty of frefb 
air ahould be prencribed. The parents ahould be n-amed of the necessity 
of thorough Tontiliitiou of nunMries au<.l sleepiag-rootus, and the child miut 
be sent out aa much as poanible into the open air. It is important, how- 
ever, not to force the imtient to take exercitie when biti feeble pon-ers will 
not admit of bis deiinnc benefit from muscular activity. If bu weakoew 
be great, tbe child should ^ out only in a carnage ; and frheo in-doon 
oare should be taken tbnt his wearied mnsclea are allowed a sufficiency of 
needful rest Ab be mends, bowovnr, he Hhould bo urged more and more 
to exert him»elf, and in seTcre cosm a dceiro for exercise is a Taluable 
aipi of improve in put. 

Tlio child must tnke plenty of nitrogetiouH food, and if, an ttometime*) 
happens, the ftppctJte i« poor, with a special dialike to meat, his fancies 
must be i!ou&ultQd in evtrj' way pottiablc. Often a child will eat a small 
bird, as » lark or a wiipe. when be turmt with disgUHt from beef and 
mutton. Founded underdone meat spread upon bread and butter will 
often be taken, ur the inoiit may be difiueed through a meat telly. Bggs, 
milk, and iisb are all of itervice. iiud a moderiit« quantity of fariuaceoua 
food may be allowed ; but the child muRt bo prevented from taking starchy 
matterfi to the exclusion of more nutritious articles of diet When the 
Appetite is poor, it may be often improved by tftkiug three times a day a 
drop or two drops of the dilute hydrocyanic acid (P. B.) with fire graius 
of bicarbonate of soda in infusion of oran^^c pc«>l. The draught can be 
sweetened with spiriti^ of c'hloroform, and should be token an hour before 

Iron is only to be rcsortwl to n« an addition to the more geuernl meas- 
ures for reetoiini;; nntiition and improving digestive power, and it must 
Dot be given imtil the dtMonlrr of the gastric functions has Ixren attended 
to. Iron nets far more energetically when it in combined with apericnta. 
Often, indeed, until the bowols have boon well relieted by appropriate 
purgation the remedy scciua to be jx-rfcctly iiit-ri. Not seldoni, after pir- 
mg an iron mixture pentereringly for a length of time without any sign of 
improvement, I have noticed an immediate alteration for the better when 



tha chalybeate hm 1>m*ii exdiatiffed tor n mnniiii^; and «Tening dosrn of thv 
OOUlpoaQii Mima iiiixtum of the Britiiih P]titrmn(x>p(i'i.a. Thn form in whUrli 
tbe iron ia pvca in of Littlo importimce. Tlio duw ahouUI iU^tu^'s Ij« oh 
Urge « ono as tbe cliUd caii btur witliaut diucumfort : and if the digfistion 
bo in good order. tJie acid preparatioiiH are to be preferred aa a rule to the 
alkalino fudta. Still, if thi>re he our remains of catarrh of thio atomaoli, tho 
ommonio-citrHtb »liould Ixi ^iveu with an alkali. MoeL cliildnm bciir tbo 
Bulphate of iron veeH Fur a child of six jroan old. &\v griunn of the <lri«l 
Bait may bo giT«n in a teuMiw>oiiful of glycerine tliree Umeti li day din>cUj 
after food- Tbia doaa may aeeiu rather a lar^e one, but it lit mrc to fiud 
any Hi<Tiu( of irritation produneil by the medicine, and the toiiic eStsci upou 
tbe s^-Htmii is uuuidly rapid »nd d»(<idoi:L Tlio |)«rclilurido ia also a ^ood 
form for admiuistratioa of tho remedy. Twenty to thirty drops, well di- 
luted with wst^r and sweetened witli plynorine, may lie taken after eaeh 
meal. TheKo prepiu'tittona are far more imefut than tlie vartnuH iron gynips 
wliicb aro oomiuonly preferred. I have Rc-cn many a rom of Huomin fin:«- 
ing from gaStrio oatanli. prulougvd 1>y tho uau of thoM Rynpa, which 
promote acidity and flatulence and cucouragu tho excessive aecretion of 

Li (tome chUtlrv-H almost all forms of iron aeom to act u direct iiriUmt* 
to the irtoTnarh. iuducin^ iitiligefttiun nrid pecvinhnesa of t«auper and cuua- 
iog wakefuluesa at uiglit. In thei^e i:«j*e» the dinlyned iron ia the best 
form in which tbe remedy paq bo lubninistored. Pure chalybeate waters 
are olao of eervi(») if the child «in 1>e induced to take them. Their value 
is, DO doubt, enlianced by the tmsh country air and exerciea by which the 
ebanf^e to a cholylwntc fipriii}^ is usiinlly a(;ooui[)anicd. 

uodftr the nw of iron tho red oorpuedes iticr«ago ia size ftnd the pro- 
portion of luemoglobin ia therefore largely nugmonted. Tlio improrement 
ia announced by a healthier tint in tbe complexion, an improvement in the 
appctito, and, if the child had been previou.ily listleas and dull, by greater 
Inwdom and spnghtliiitisH in bin movuiiK-tittt. 

Arsenic in auoiher remtidy of grt-at \iduc iu ituprovitig the coDditiou of 
the bloud. Cbil'.ln'U bear aru^ntc woll. Tlie drug, uuIphs given in very 
}hrg6 quantitiea, is rarely a cauae of gastric irritatioa. In tsct, an is weU 
known, amento in niiiall do»ea is a r,tluable ftedative to tlie di^eatiTe organs 
and often nrro^tj* voinitiiig. As n t*inic th* remedy abould be given to a 
child of six years old in tJi*; doso of three or four ukininis of Fowlor's solu- 
tion directly after food. When the digestion ia greatly impaired by ro- 
j)eated attarku of gastric catarrh tbn effect of thin medication ia often very 
striking. Tlie nrsenici may be n-sr-fully condiiiied with a drop or two of tho 
tiwrture of nux voniicji. Another rcuiud^- from which goiKl rcaulUt hava 
been obtained ia phospbonia. Tbia powerful drug may be safely f^vcn to 
a child of Huc years old in dosea of ,|^ to ,1^, of a grain. I have, bowerer, 
no pcrsooal «xpene)ice of itti value. 

Cod-liTcr oil ia of Bcrvico us an additional food, nnd in combioalioo 
with iron u*iue ia a favourite remedy in all forma of nniemia in young aub> 
jeola The alcohol of tbe viaura ferri is no doubt a valuable therapeutic 
^^L ageui Alrohobc atimulantA taken with footl help to promote di(^ut<tiou, 
^^B iodin many pallid, weakly children bnve great virtue in aiding tbe n'tuni 
^^H to health. Sound clar«l, or tho St Kuphael tauniu wine, diluted with uu 
^^F equal proportion of water, is usually taken readily by the child, and ia a 
I eeiisible lidp to oUier treatment. 

I Cold-water packing ia naid to be uaefid in improving tho condition of 

I the blood. I>r«. M. i*, Jocoby and V. Wliite have reported a series of 



cases in which anaemia was treated by the regular application of the cold 
pack followed by maas^e. The patient was enveloped in a cold wet sheet, 
this waB covered by a drier ^eet, and over all sis blankets were laid and 
carefully tacked in. After the lapse of an hour the coverings were re- 
moved and the akin and muBcles were vigorously shampooed. This plan 
of treatment was combined with rest and careful feeding, and was attended 
by very good results. It might be employed with advantage in the case of 
weakly, palhd children in whom anorexia is a marked feature, for one of 
its most pronounced effects was found to be an immediate improvement in 
the appetite. The induction of sleepiness by the pack and massage is 
usually an indication that the patient is benefiitmg by the treatment 



EbnoBaraosT of the epleen is «oiiimou in early Uf&. and is found in tlio 
oourse of a van«tv of ai»eaa(ts. Tbc symptom is alluded to tiicidi-utiill,v in 
ibe d«Hcription8 of tlie varinuH foutm ni lUiieAH in wliicli tlii^ pbetmmeunn 
occuts ; but tbe subject ix of siiflioinut iutfiortaiiott in u cUnioul point of 
view to deaorve A spociAl ohApt«r for itu coiifuilcrfttioo. 

A »plenic tumour nuiy he of acute or rlironio growth. Acute eiilar;;v- 
inont is )M.-«n in tifihoid fpv(?i'anda(^e,f<ni]iptiiiieKij) aciil^ tubeiiculoKiD, and, 
it t« wtid, in ccrelwo^iniit fnvrr ; nJun tlip cnlnr^ed spleen found in oases of 
lencocftbetma may be invludod iu Uiia claan, for in eoHy life kuklu&mia 
otieu rana nn acute cuiuxc. Rapiil increase in taze nt the or|^i is also oc- 
owDoanlly met with aa a retiult uf picnic embolism iu the counto of ulc«r&- 
tiyt cudocitrditijii. 

Chronic enlarKtment of tlw Kpleen may be tb« oonaequence, an<l iwiuo- 
timtiB the only nmnifc^iitatiou, of tbe cachectic cunditiou induced by niiiln- 
tious poison. It occora in some cases of aniy1oi<l ilet^CDtmtiou. although 
■ 8p)e«a so ufTected is not nin'uytt iiK'reitbed iu si^o. It lh a coiumoQ synip- 
torn of lynipbiii1t>noiuH, in not imfrciiueatly u c<vutic(]uence of HtiYipliio 
oiiThoaiH of tbe liver, and iniiy be met with in oshdh of nld-«tAtiding dis- 
ewe of Ui« heart. DiAtly, it may Ih> due to n simple liy^H^rplimiik Hyper- 
trophy of the splecti iiiny occur in rickets and syphiliK «^»«p4x-iidly tbe Utter; 
bnt is also futuid in cases wbero syphilis tuny l>9 positirely excluded, and 
lit ca«ee, too, wh«re tbcro is no reoeoD to «ui)p«ct any malkriouu origin of 
the swelbng. 

In tlie child a upleen ia not necesKarily diseased liecause its lower edge 
is within reach of the fingor. The ttealthy orf^an is sometiioos pushed down, 
so aa to bo felt. Thin diuphK-ttuiunt may occur in oosm of copioiia effiieiion 
into the left pleura, and in common iu rickeUi where there is much reti-a>>- 
tion of the riba 

In determining tbe enstence of eulai^ment of tbe iq}IccD it is not sttf- 
ftm-ut mert'ly to aacect&iii tlie position of the lower txlgc ; for conrideruble 
mrelbu^ of tJie organ may be present although itu iufei-ior border does not 
protect betow tbe morion of tbe Khs. In the child the t^Ieen oftt'u extends 
muwnnlsand upwards aa well as dowiiwanla, and niny reach pustcrioHy to 
the spiuid cohnuii. By percussion iu such coses we can often detect duluem 
in tbe axilla reaching upwnitls as far as the fourth or fifth rib, and in the 
bock, extending aa far upwards as the inferior angle of the scapula. In ail 
OMes wb«re n splenic tumour is susjiertad the aze of tlie on^nn should l>e 
eetimated by percuHntion nx woU as palpation. Wliou llie lower juu-t of tiiu 
orRAO projecte below tbe tiXm into tlio abdomou it in easily felt by layiu;; the 
luud nat upon tbe lielly and ]>rcauii;; tTcnlly with tlte linger tipH. That 
the HwolUog Unis discorered is due to increase in aize of th« splet'u is indi- 
cated by the superficial position of tbe tumour, by thocomparataTe thinness 



of iU inner Ijonlor, and hy tlie nt)(cli ■which cim often be dintiuclly perceived 
bj the linger. 

An eukrgeil spleen is usually firm and resisting to the touoU, enpecially 
if the enhurgeiueDt is a (.-hrouic prvctBS. In tjplioid fevc-r, however, thu 
Bufaatance of the Bwolleu origau in luiiuninUy itoft, mid ou LhtH aciH>uut can 
sometimea be only f«U by u pravtisud finger, lu urute formij of sweUing 
tlie iiKi'<?A>M in Nze is a<xmmiuuiie(l hv &>oiii« tendentess on iiremure. Id 
chi-ouio eiilarg^TiieiiU thei-e may be aho teuileruem, but thbt i» ooonmoDly 
diu' iu »iidi amcs to the prt-s^noe of lo<!nI pdHtuuitis. 

Id tiie })re&«nt chai>tcr it will be xmueccanM-v U> refer again to nil tbe 
foriuK of splpnic tumour met with in tlie child. It will be siiffirient to con- 
iiidnr tho tihronii* eidar^enictit which occurs as a consequence of a aimplo 
h_\TKiri)In>*ia oftUf-- orfijan. 

■Sint/j/tf Utfpi-rplana of the apleen is a not uncommon condition in in- 
fancy and early cuiltlhood, tJften tlie patient mav bear tracea of inheritei^^^fl 
svphilia or show Home itynip1oiu« of rickets ; but ttia is not alv,-a;,'H the oa^^^^I 
and etuiuclimcti no nifpi of diathetic duicam or coiiNtitiitiounl weakncsa ift^' 
ouywhcrc to bo detected. ^Vhcn the cnlargciueut i» thii!4 pn-scut iji n child 
of apparently healthy cuuHtitulJou its etiology is diAiciill to establish. Iu 
some of the cases which have come mitler my notice the enlargcmeiit baa 
been preceded by gaetro-iutesUnal deituigemeut Iu othera the cliild has 
been §ubject to frequent attacks of pulmonary catarrh. Sometiniea the 
Bplenic tttmour was Arst diseorered ehortly after an attack of meaKloo ; but 
it is diffi<nUt to admit a connectioa between these dernngeuient« and the 
aplenic hypeqilasia. 

Morbid Anatnmt/. — "WTion enlarRCMl from ainiplo hypertrophy the sploaa 
rctaini) its normal ftliapc. It is fiim luid amuuth ; itti cipwlc i» thickened ; 
and a section shows n pale red or reddish purple Hurfaee, with the Malpij^uan 
buiHes more or less diatiuctly vimble. 

.Si/>')j'^om.i.— The existence of enhtrgeroent of the spleen in at onee in- 
dicatctl by the complexion of the ehiJd. The whole body — both ekin lUid 
niiicouH tuembiuneii — is j>ali> and bloudlesH ; but the tuit of tli« face is 
obaracterietic. It has something of the colour of ivory or wax, with the 
addition of a faint olive cast which is not found in either of these substnucea. 
Often we notice a curioua tnui8pareiicy, especially al>out the nioiitli and 
eyelids. Tlio belly is large and tlte spleen onu be readily felt as a smooth, 
wm macs. If the increase iu size b great, the tumour proi«cte diagoonlly 
across the alKlomen, and presenta on its inner surface the abrupt e<lge 
broken toward» the middle by the notcli. TTmiaUy tlie organ pn*jects up- 
wnrds and to tho back tix well as downwardn, and ita Umita in thciu- dirciv 
tions can be estimated bv pcrcuasion. SometiaioB it is froely movable by 
the hands. luid it always descends when a deep breath is taken, rising again 
in expiration. 

Although pole and bloodlcns llic child has often a considerable amount 
of ih'Nlt. and in greatly wnated only iu C-iceptionnl caaeo. He is, bownvr, 
weak and hmguid. The bowels are often irritable, and in children of three 
or four years old the appetite is capricious and perhaps perverted, ao that 
the [Atient shovrs a curious tendency to ent cinders, olialk, filAte-pencil. 
and other gritty or even disgustiuij: substances. (Fdeoia of tlie lowen. 
limbs and evelids ia sometimes noticed, and petechliB and bruis«-lil 
patches may be present in the skiu. There is also a marked tendency 

On examination of the blOoS the red corpnadea fonn rotikaux in the 
iwtiAl mimaer ; but tested by t&o hgDmacytomotor their somber is found 

[,EB»— fiTMPTOMS. 

to he reduced ci>U!U(lonil>1jr lx<lnw the normnl nverng^, and tho white cells 
aro ofteu spprt'cinblv iuoi'daai'il, jilt.hoii{{h st'lilotu to th« dci^ee obuerrad 
in cases of loucofytliernift. Somotiino)) botb red and wliite corjiuecles on 
irregtUar iu Hlispv. 

A little boy, ngod one year and sevea uaontLs, wait said to have heeo 
liom Btrong aud beiUtliy. He was the ynunp^oat of four, inn aiders boiag 
aU titroag and vreiL He did uot HDufllc aitw birth, our nciv nay spots 
noticed ut tbnt tiui« ou llie buttocks. L'littl the a;;e of teu months the 
child excited iio uimvlj', but ho Iheii began to get pole and to lose flesli. 
He had been Ifit«lr ver}- reetlesa ftt night. 

Oq exaiuiiiiitioii tlie infant wns Reeu to be toij onicmic o>-cr the ivbolu 
Ixxljr, ftiid h'vi <'iiiiip1e\ion ^\'[i<i ut it dull ^oUotvi^b- white, eKperiJiUy on the 
efaeekR He vma thin ii]t)iou;;b not eiiiMc-iiit«tl, and hia oxpreRffloa showed 
no sign of disii-caa. Tbc cbdd vfiiti tlie 8iibj«ct of hlight ricketn. be had 
ouljr two te«tli, hiH chest was a little lLitt«in'd lattmdly, luid there waxln- 
■ignificaut oiikrgiMiictit of tlio opipbysos of the long boiieti. HIh I«gH yvtire 
eioalt, and h« bftd nevor been ablo to walk The fontaaelle waa about h^ 
an inch in diameter. Tlio fronUil bone van rather prominent on each side 
of ttie middle hne, and there wiut annie iiieoiiidderable thiekeiiing of the 
parietal bones. Cnnio>tabo» wug woU inarkod. 

The belly vraa very full aud [jromincnt, e«p«<;ially on the left side. Ab, 
the child lay on hbi back, the lowt-r borJtr of the spleru was found to reodi 
to the left crest of the ilium, and the inner nmrgiti jiiwscd obhijuely down- 
wurde fn>in bcnt-ath the ribs to within two tiuiiurD-brcudlh of the rigUt 
anterior suporiur spiuu of tbc ilium. Tbe uutc-h van felt just idiuvu th« 
umbilicus. Tbe urgim vr.m freely movable, descetiiUiig apprtciitbly in iu- 
^irttioD, and it could be paalied upvcai-ds until its lovrer border vfM on a 
level with the iiavcL ' It^ Bubulaiice was ilrm and hanL and its eiirfaoe 
smooUi. Tlie upper border, eetimat^xl by purcusiiioii, fot^o to uithiu two 
fiugeni'-breadth of the inferior angle of tBe left Bcapulii. The edge of 
the liver was one inch below the costal margin. A siikidl nodule could be 
Jelt OQ each aide behind the rnmuit of the lower jnw ; otherwise there vaa 
no eolurgeawat of the lymphatic glands. A little blue mark, like a braise, 
-was DOtieed on the forehead, and there n-as anotber ou the 1wwk. but thftro 
were no petechiie present on the »kiii. There was no redema of the legs. 
The cliild's appetite waa good, and he wa8 not siitferiug hmm digestive din- 
turbanoe. .\n oxAmiDatioD of the blood ebowed no exc«ita of white cor- 

Children in whom great enlargement of the spleen, exists are very sub- 
ject to gas tro-i 11 testinw trail biea, and in coiiBeqiienoo of tboir weatcuosa iwe 
frequent »uirur<:rH from every form of cutarrbul dvraugeuieiit. Iu fact, 
t^ey usually die from a suven.^ chitrrhuLVi or an attjick of liroui^liitiN or ca- 
tarrbalpneumouia. If they escape tbeue accidents recovery is not iuipoiwi. 
ble. We sometimes find the spleeu gradually diminish in size and eventu- 
allr return to ila normal dinienitioua 

A httla boy, aged twelve mouths, with no teeth, was brought to me, ax 
fa« was s&mI to be weakly. The child bad l>eeu reared by hand, and wn« 
subject to attacks of sickness. A short time previously, during; a 'vudt to 
the ocogiJe, he hail been jaundicud. There was some slight enlargement 
of the ends of the hones and bis fantauello was large. The child could 
not stand, bul liked to bu dnuccil aWut and playetl with. Hiscompleiion 
was excessively pule, with a fsint olive cast. Tlie nbilomen wua full, (uid 
the spleen, whicb vran large and hard, reached to the level of the navel 
Ibe diiUl woe put upou a nutritious diet, aud was ordei-ed cod-Uver oil 



ma |4Mrt;^ mT Cmli lir. la ftfv meuOmr time be faid ai« tea tMik. uiJ 
llHbuaKlt «(«U f*l«, bed * belter «ocBplexioa. Semi moolfae efterwnrds 
»«■<¥■ faw to ami rlrit) he laJ rfrtwti teeth ^d ooold nm about mO. 
(lit e|4M>>i «M ■*>« IP ■ill/ fadaead ia Bsa^ baiag fivt pemplible befcw 
llrt n)A ilie eov^nioft waeipwd and he aeemed pecfecilj wcIL 

lit Itiw mm no ^iMial nettaatiaD waa atiesii|iie<l witli the object of 
rwltw'ini; Die m/u of iiu- siilcen. Tba goaerel waaUjr rui« \rnB irapnmd 
hf fnxtli Kir eixl « Niiita>>l* <lj«lary, aod cod-liTcr oil was giren oa account 
t*1 Itiu oltfitii of iu«-i|n>iit ricJurtA Uoreorer, further tnb'stiiial catarrhs 
Met)' )'r»tfiilr>| l>^ II cKrofoDj amdicd nbilumiua] bandaK*- Tbt> bupe that 
tihiltir lliiHwi ultiTf"! crtiKlltiotu Uie aiae of the BplMnmniM diminish as the 
((W" I ' ' '1 wiMt ]M-rfe<Hlj^ jutftificd l>r the erent. 

/ . .u liilli- ilifltniltj rIhjuI tliv cliagnoidti nf th««ie easM, 

Tl" I '11 "1 iIm' ''liild iH iret;^ ebaracteristio. ItKlecd, in a vmiOK 

•i>iti ' >iiMi ipiin wli'Hitd alirayii dirtct ottentioci to th<.- ^plevu. \MieD 

a liniil Jiiiii|i im diacovrml iu thn lefl mdo of tLv lUiduiiu-ii, it is eaay 
tit iw'i rUiii If lh» ■wvlliiif! in duv to itpleuic culor^vmeut. Ttii) KU])erfiniiU 
jHHill.loii of tliK (iitiKJtir; iu \m«mnn iipwartlti bpnealh the ribR ; ilR U-es 
riiiiiidnl liiiiiiT ixluu, vrilti II |>orcflpLil)l<: notch; the free inubiltly uf the 
iitiuM, whlrh Diui l>(i presRod tipwnnhi hj Uic fiogrrH. oud may be iieeD to 
(ituvfi til DorrfaiHnidrara with r(iii{jlrat)OD, deBoeiidiu(' when n de«p breath 
l« dniwn. mill ri>>iii[f Aitniii i«itb tho diaphzacm tm the luufpi coulraci — ail 
(ht)wi MtriiM l^invn lilthi ilnulit uf Uiu nulure of the enlargrnieDt Tluit the 
tuitinfiii'lloii 1« II Hiiniilc ht)H<i-lniithy. and in iiot duo t^ Irinphfldfnuiua or 
|niti'<>i\vth<>iiilii, i*( liiivtTP<i fniiii iV ubflf'Qca of htupbatic onlar^ctneiitb in 
IIhi fiinii*<r «itm<, luiil in Iho Utter (rout the uoall uicream in nuniher of the 
wUH' "1 M ' 1o« nf tlin blood. 

/ Thii pnMpMi* of thn child in simple hyp^riilnma of tbe 

Hiiltx'ii iltjniml tti a K^rnt lui'Miiro »{»)» tlio ciiTO beatowcd u}>ud bitu, aud 
|[ii> Muti'hitihiciM with nbii'li n« i<i (,<iifu-il4>d from inierourrt'St aibneuUi. 
Tlifl |ti-«iiitiwiii ia tltrmfoti) iniiHi morif (ivoursble in the oast- of chi]4livfi of 
Wvll t>>-<l« imri'iilit tlifin iti IhotX' Ivloii^ti^ to tbe dasa by wiucb our boa- 
yWnlm itr\-' mipiibiil. If llio )niiriil ttliow marked aigua of rickota or sjptu- 
ila, n iniM< t'M)) llA^lty Iw HiilH-iitfitixl : btit if tb« aigns of rideta are only 
tii(»>lr<riil4'lv dvvt>l»|xil, or thv Hviibiltitc oti^ of tite enlar^dDent ia mmtiy 
a iiiaHor «i( iiii«i]i«4-ioii, tbe child, uniler fiftvuurable oooditioDe, lias a fair 
i>tMiti<t> id rvt^i^vrr. Alty eoumkWrable exoeaaof white rmptnrlm in the 
lilotv) iwuni gnutiy diwiniBh wur hopee of a aneeasahd leRiuitatton to tbe 

Viyntmr^K III lhi> IrMtmeal of oaaea of aatple hTpcrbwl^ of the 
■pliM'n M-n mnmt not allon- Mir aMaaAiOB to be diiMled top earJMini^y t» 
Mf 'ifKik, 1(> the iM|ri«<4 of ih» gettecal health. Much iqj 017 ia 

i^t< > Uwe <aeea byioa^ v w t n m of a wre ni y or JodiJe of p<ila»- 

wbtm,, aatd the eaan yi tif «pph«atMa of M eti mria l outtnMnts to iha Uk 

Om Ar*l .are AmaM be to ■lti«ilto«nyi,iiitiii iitiiitiiiil iliiaBfci»i ■< 
ntu.). m^;i W tM«*4WiMr wiUi the pMtfeatV Mdriliea. Tending bhi ha 
UvMNM-M M tW K-nmb wwai b* arwelii. asd the Aal waM he 
w....^) M aa Kt Mf^t^^ the «KHt aaaBik> iii«riiihwil wfe the kaak tax 
H|Mll na tU|M^ |>vftv«x Heat or the pBlMta am wmiit dOdtHi 
waW t«v« «Mws «k( 4^^ IWt- «Mii thmia i ha dieted vxn the 

mum tfaepnK 
llflk. v«Ac< 

MvJlbi'k 1^ €^«nmvSk«a «Mtr. hrcthi. Oia W«mI a»4 WkK 



in a looiinr nud atraiuetl tlirou^tb a fine mcvv. should be girnB. Wntcli- 
fiilnesM muHt be Cierciaeil tluit tliH mzp anJ frequpncy of the meals ai-e 
dulv proportioneJ t/> the di^tive capabUitieH of tli«> patient; and in th«H 
caac of u)Uk. in particular, it ie important, by careful inspecUoii of tlie ■ 
slooK to Kitirif/ ourselves tlint cnrd is nfit jMianing awft,v iu liu-go quaiititica 
by tlie bowuliL If this be the case, milk Kbould iiot bu frit-en pure as a 
dnak, but be altrays luixod witb b*rley--wftlcr or other thickening material, 
so as to aiil its iligestioti b.v insuring n fina flivisiou of tlie curtl. Three 
or four (rmioit of pepsine, given just before the threa priiiciptil moaU. will 
bo of greiU (wsistnnco in tliftse ojum>s- 

Having attended to Ibo diet, attvaliun Khould uoxt be directed to the 
cltthing of the child, Tiicso putieots. OMpccinllj if they show any tiigng of 
ri«k«tit, are very Kensitive to eLuiuges uf teuipemture, and it i«i of extreme 
importaaoo tbi^ they should be thoroughly protcctctd from chilU The 
beUj should bo covered witb n bruiul fliuiut-l biilU Tbtu niuat be applied 
carefolly, ho as to cover the whole of the abdoineu, from the liips to tha ■ 
waist, and should lit cloaely to the flkin. In eol<l or changeable weather ■ 
thu uliild'H legH ftud thighs ^lould h& protected by long woullt-n stookiufn, 
sad all hu> uu<1orelotluug should be of llujiiiel or wooL So prot«ct«d, Uie 
patient miut be taken out of doom ati much as poaeible, aud ui suitable 
weather should pass the greater part of the day out of the housa. Before ■ 
he leaves home, his feet slioiild be emmiiied tn see that Uiey are perfectly ■ 
warm ; and in cold weather it is bfist to piuilc tlii> pliild in a perambulator, 
BO that his biu-k and md<m may bo pi-op<M*Iy tinpportcd. His foot can then 
reai upon a tiot-water bottle. If the ]>ationt bo aeut to a good seaside air, 
the effect of thene measares is often rtry marked. 

For mctlieiiif, unlosa there ore podtiTe aigiifi of syphilis, merrm-ials 
nod other lowering dni^-» should not be employed. The best trcotmeut 
cotudsta in tJic use of iiuii iu full duties and cud-liver oil : but this treats 
mant must not In> begun until the bowels Imve bf?«n put iuto a healthy 
itAte by Appropriate reme^Uea. For a child of eighteen months of age 
twv or thr«e grnius of tlie e.\8iccated sulphate of iron may be given in glji'- 
oerine : or U>u drop« of the tincture of percblorido of iron may be admuii^ 
tared, freely diluted with wat«af and aweelened -with glycerine, throe timeg 
a du after meala Quinine is also of tiemce, and may be fi^ven hi oou- 
jnnCiiOD with the iron. The value nf alcohol nuist not Iw forgotten. A, 
teaspoonful of the St. itnphael l-'innin wine, ^veo two or three times a 
day, dilat«d with aa cciuiu ijuantity of water, is an important addition to 
the treatment. 

J have emplnypd frictions with merdnriil salves to the eplenic region, 
and seen thoni use<l by others, but !inv<- iifvei- iiotiofrd any special benefit 
from thiH pi-ticccilin;;. An n rul«, it hiia aveoicd to me that the uiouuia 
baa been intensified by thin menns, aud that the size of the spleen b«8 in- 
ereaaed rather than diiuimHhed under the use of the drug. UnlesB the 
employment of the remedy is disUncUy indicated by clear evidence of the 
pxesencc of s>-philiii iu the diild, thi^ method of treatment seems likely to 
M attended with a bad rather th&u a good result 




H^EuoniiUA in a cougrnital tendency to bleeding vbicli manifests its^ 
shorUv after birth and Issts tlie life of the patient. Tb» binuarrlM^ oc- 
cttrs eiUior spontaneouely or upOQ sU^fat {irOTocftlioii, aixj con onl; bo 
airestetl with great difBculty. The twibjecta of th« disease nlso ftjibibit a 
curious teodencr to obKlicHte Hwcllinj^ of Urn joints, Trbicli ore often 
irpok«u of OH "rhrmniatism." A tamponm- dii^poaition to hn^norrhag*^ 
such flfl is soiiu-tiiucs k-ft aSXtv oeittun diiieiutt-s, does not oonttl ittilt! luuno- 
philii. Tlie lni<^ diaense dnies from birlb, or sppenn i^OTtl,v afu*r it : it 
olwayR MM>n in ohililLuod. niiil poraLstB, as n rvio, to the Toy «id of life. 

(Aiujw^ion.— Hivmophilio, if not inrarisWy htTcditarj", Miowa a aingular 
tcndttDL'}- to brrfditnrj trnnimiiBBion. Ttw pntdi^-ity monifestB itself more 
ijuently in the niaif than ia tbe frmnle of^kpring ; l>ut the feuia](«, if 
liemaelveR escmirt from this pPCUlLirity, are Btill cnpniilp of tnuismittmg 
!te diseoBv to thi'ir cliiiJreu. It is, uidix^l, a curiouii fiwt that tbc frons- 
^nissioo of (be tendency to the child ix srfn more comiuonlT in cawB wh«re 
the jntieul, liliether moh; or female, although sprung brun a fauilv of 
bleeders, is indindunUr free from tbe bfemorrlia^edis^toaitioQ. It is rare 
to Hnd ft father tnuutmit the disease to his child if he is hininelf a suiVerer. 
the ninjorilj' of ease« the unfortunate inheritance is derivvd from the 
3ther, who has prolwbly escaped 
In a fnniily siibjt^ct to this tendency all the male ebildrea may Vfore 
bleeders. Somi-liuios, bowcTor, one or mora esrape. Dr. Wiekham Le^ 
is of opinion thnt n-hen traiisuiindon is oidy jxirti&l the timt-bom are more 
exempt than the others. Tbo disc-nsc is foiutd in all countriot and all eoD- 
ditions of hfa Tlie Hebrew race i» said to be pccnliorlr liable to it, 

Morbifi Atialomy.~la eoiim of death from kfrmojihUiu little is found to 
«xplain the nature ot the disease. The body is ueually blanebed hon losi 
of ulood. but the organs^ eflpcclslly the heart and Itu^e veeeels, present no 
nppeanmce of diseooe. No ehaoge is du«eoTen_'(1 in the blood, and the 
vcaat^s seldom present any alterations recoftnisiible by the microscope. In 
Mumo coses, indeed, a partial fatty degeneration of the li n ing membnuie of 
the arterieti has been observed : but this is j^rolxtbly the conHeqiieiice of 
the anietuia. Peteohiie in the skin, and bmise-like patches from i^nilMTuta- 
ueoiut extraraaation, toay be found : nad flometimos larj^o coUectious of 
blood have been met with. ^ W. Jenner has reported ti>c cose of a hoy, 
a,v,eA Ihirteen jnu^ tn wboin on enonnouH extravasation of blood wns dis- 
covered beoeatb tiw fascin of the right thigli. The swclUn;? of ihc joints 
appears to be due to pstmvnKatitia of bktoti into the urticulatioiis. In s 
cose reported by M. Poncet. on ojx-niuj' the kneo-jobit, which had l>een 
cbstinalely ewoUen and pninful during life, all the tismos of the articula- 
tion were found to bo staiuL-d with bloo<.L At the circumfcrcncs the tia- 
iM were cbocoUte-coloured ; the orticulAr surfaces were red. and impreg* 






nated with blood ; and the cartikgoK ii-ere the seat of advanced leaiona 
Hucli aa have been described b; Charcot a« cliarart4!n8tic of chronii; rheu- 
nutiian. MLcmacopic eumui»tion revealed in the xubstADCc- of llie tiasties 
ytUovt gmiuloM, irregulu- or rotiudo<1, aad of vnrinblo 8bt«, pigmeot gran- 
alea, aod fst grauules. OHkv joiato in tbo same subject sboired simUar 

Symptojwt — ^Thero i« nothing in Ihc loolc of th« child at birth to indi- 
cate my peculiaritT of eonrtitulion. N"or in ftft4>r yem*, iinless the in<U- 
vidual be actually sufforing (roni \oen of l)lood or dtaeaae of the joint*), ia 
tbera anything in liia appearancn to iHHtinguinb him from nnothnr vrithoilt 
tbo wimo tm<loni>y to hioExl. Tlio chiM may bn fnir or dark, toll or short, 
of robust &anic or of alcnder build. As a nilo, he lookit hoaltbj, onJ bis 
intetlactuol capacitv ia at>o\-e lh« ikTemi^. 

II IB rarely before the end of the tirst twelve months of life that any 
Btga is Dottoed of tho hiomon-hagio di-tpoaition. Bleeding aeldom oceun at 
the time of separation of tbo unibilica] conl. or during tbe opemlioa of 
Taoouwtion ; and il in not until the infant is able to cruwl or walk, and 
thus beeomed es^sed to injuries fniin talk or other riolcuee, that hie ood- 
sHtutional pernliaritj ran fte rern^niHed. Soiiietiinofl, however, eridence 
of the dtttenw i« potttpniied n iiti] later. BIe«diii;T may not be noUoed until 
the second oroj) of l««>th be^iia tn tiiako itti npnefirance at about the aizth 
year. It hm won been know-n to comfi on for the first time at a later 
jieriod ; but is nu-ely delayed till aftei* puborty. 

Tbe {m-ippRHity to bleed Tariea greatly in its intenidty in iliflTercnt aub- 
j«etfl. Ui the lowest degree it mny Hbovr itself merely in tlm nhnpe of 
eedjymosea in the skin. In a hi^hvr gmde Ihu piiUeut may «^«mplaui of 
qiODtaiieom bnmorrhage from the muuoua meiubmnes. In ita inoxt pro- 
noQueed form a tendency to even* kind of bleeding is obaervetL Ulie 
muvouB meiubranes may jjonr out blood without obvious cauae ; alight in- 
juries may ^Ive riao to copious extfavaHatiou into the tiewues i petechitc 
may onpenr in the skin ; and obslinnte nnd pniuful Kvolliags may attncl; 
the join t& 

Tlie hiemorrhage usually oocum at n time wlien the patient appeal's to 
be in iinasually gotxl faealtli, for it ia at these times that there ia a plethora 
of tbo sniflller vein^a The bleeiling may 1ie ])renodfHl by Rigna of extrite- 
meut or irritability of temper, trnd il in luiid timt there itt shurpcuiuf; of 
the senaes of hcarin;^ iind of sight. Epileptifonu convuLtioiia have bi-ou 
Boticed in one case by Boii'r. 

If the bleeding be spontaneous, it occurs in the child usually from the 
Doee : but may be aIiK> notii.'oi'] from tlie inside of tlie cheeks and lips, and 
From tbo guuia, esjieeially during dentition. In less common cases blood 
is aliw pourttd out from the muoouH membrane of the stomneh nnd bowels, 
and may be Tomited np or diaohargetl by atooL As u rule, tbe younger 
the ohilH the more likely ia the htpmorrhage to come from the none or 
mouth. It is only tovartia puberty that hn^matemesia or meln?nn beeoines 
commoD. Renal hiemorrhftgo is rare, Once started, the low of blood maybe 
ixiotinuouH nnd eoi>ions, so aa to be an'catod wth the ffreat^st diiKciilty ; or 
may eeitae for a time and then return. SoiQetiiuM hmraori-linge from one 
satir<y> ia quickly followed l>y a ftirnilar effiiRion fmm anotJiPr, until the pa- 
tient dim worn out by the constant diuclLii^c Whtu bL-udiug from one 
•ooroe alone enda in death, the luemorzhage oocura usually from Iht^ nose. 

In addition to the spontaneoua hmnoiTfaagefi, sUght i^-oiuuIh or bloiva 
may produce a copious i-ffusion. Little cutsorscratcnea bleed obstinately ; 
bknra upon tbo bodv may be a causo of serious extravaaatiou : 




in eertain mil^ectii even tlio rininp; of a blister max till ihc bleb %ith blooil 
in«t«iul of ttvruui. lii micli pnliuiitu Uic extrocttuu uf ii tooLti. Uie upjiJicA- 
Uou of It leech, or the prick of a pin maj' induct* bleeding ntiicb fur a loug 
time retuBts the most powerful ntj-pticB, mid may even JeBlroy the life of 
the patiuit iu t()>ile of th« luo&t eueirgetic iu«»iurea for its nuppreiwioii. 

TL<^^ lciidfuc;i' to bk-cd, uruu iu the cohti of the tttuuv child, is nubjcct to 
curious 1-uriutiou. A slight injury wliieh at oue time gives rise to exccft- 
aive tuemorrha^ce, at another la followed hy ao iU coasequeLcCR ; and a 
child in whom rupuatul ki-iuorrlia^t^ from the uo«e or mouth &r(- a koutcc 
of aozietj- may buir the remuvtd of a tooth without uaiunml bleeding fol- 
lowiog the op«mtioii. Tims Dr. ^Vickhf\m Legg has i-eported the ca»e of 
a boy, aged eight ycara, who w&b HubieH to frequent beeinorfbiiges fiYtm 
tlie DOM nod guiui>. Tliis child could Ixt&r the eitraotioit of a tooth or a 
ent 00 tbe finger without much loaa of blood. 

In all canee tlio source of the bleeding ia cuiilhuj. 'Die bauBOrrhage 
ooonrs as a constant oozing, which tunj luiit for houn, dujn, or WLika : and 
it ig astonishing to note the rnnrniou» qmuititv of btuod which may 1» 
thus poured out by tho raoj«t trifling wouud. In the caae of trriumuric 
blticding the liHimorrh&ge uaunlly bL-gimi aomo hours after tbe iiiflicliuu of 
the injurj'. It often does not ceu«e until the ])ati«Dt becomes (uiiit, and 
even theu is hable t« renewal when consciouaneaa returus. By 1bin maims 
the child may be reduced to a etate of profound oueemia, and only alowly 
rvgaiua his colour und strength. 

The ]>etechi:i' ncd siilK-utaneous hjemorrbages which oetmr in ha-mo- 
philia are rery (nmilar to those notictxl in c4t«o» of purpura. They nrc com- 
mon OQ tbe buttocks and limbs of infiuit bleeders, but the Euco usually es- 
capes, Triflin;.; b1ow.t mny produce copious effusioos. In some canes the 
blood inRUmti^-ij (x-tonKivtly tbroiigh tlie nreolnr tiwue of n limb^ imd death 
mar eren eusuc from this inward uloediiig. Iu other casea cireutiuicribed 
couections of hlooil may l>e noticed, forming tumours of Tarious sizes. 

One of the most curious fentureH of tbe dtaease in its higher grade is 
the juiLut affoctiou to which tL<-ae patients are so subjecL The articuhk- 
tious attacked oik iictuidly the larger ones, and to the luaiority of taaea ii 
is the knee which suQ'ers : but tlie ankles iLud hips, tlie shouUlei-s and el- 
bows are liable to be aff«cted. The joint becomes swollen and tender, and 
the swelling usually increases until the ends of the bones can no longer he 
felt It is accompanied by pain which is incrensed by movement, imd 
there is a rlec of teuipemtura Sometimes Huetuation ntny be delected. 
Tbe Bwelliug is said to bo due, in some cases, to u simple effusion into the 
joint ; but it ia more foinmonly the consequence of arlicuhu- bKmorrhagekj 
It may oocur either spuntonenusly or as the result of a tiitling injury-, 
symptom pcntiatii for a mrJAblc time, and it may be months before the 
joint rcturuH to its unliuiiry dimuninons. Suverul joints luay \jl- attacked in 
Baccassion, or the joint atTeoLiou may alternate with some foi-m of visible 
luemorrhage. Blnud tumours sometimes rise on the sides of a diseased . 
joint. Titun M Poucet ims retx>n]cd th« cuue of a boy, aged eixteeo, whc 
right kneo had been ptibful. aliS, uid tswoUeu for two yuani. tioiue 
warioualy a small sweUiug had formed on the inner side of the knee. 
Titis had turned black, and then h&d burst, giving rise to ohatinate hirnjOK-. 
rhage. The boy was vor^' subject to profuse bleedings from the ddsm 
jmd eventtudly died in cousetjuencft of repeated, luemorrhage from -wouiidB^ 
made b; the applicntion of the actual cautery to the diseawd joint 

In atldilion to tbo articular afTection, paina may be complained of a 
tbe liml ' « joints, altlion^ unaccompoBied by ewelling. The ~ 

rtMUovrxiLi a — st« pto sts — diao xoris. 

iiiay b« BO seven? iw to interfere with eiprcise. Tlie subJMts of lutmo 

{kliilia iiltK> suffer much from cold. And the luem4>rrhage maj be det«nmiied 
»v irspOBiire to weather. 

It might, perhaps, be exp(Hrt«>d that the esistenc* of the conatitntioi 
teudency wmiM inSuttnce unfnvoumblj tho coiir«« of tlio exanllir.nintA aii< 
other iDtcnnuTOQt diaaBBM to whicli chiUlhofKl is linblo ; but this do6» iiol 
apjicar tn be the ooset. Heaiile^ Hcarlet fever, and wlioopintr-rflut^h are 
inkl to run their normal ooiinie iii such subjects without nmiiifcRLinj' ex- 
c«ptao&ally unfavoiirablo Rymptouifi ; and althoupih tlic patir-ntt are prons 
in rbettt affocUotu), Huoli iM ptfuriny tind pui-uniunia. thcHe diHoiUK-s an- nuL 
att«iitded with Hpecial duiigent. There in im pecuUnr liability to phthiuH ; 
bat aliHiffhing and gangrene are wud to be not uncommou nwidentH in ths^ 
■coone oTvrouwU and traumatio iujuri«o generally. m 

Diagnoiis.~-ln pronoiiQced cntws the detection of the hsBmorrhaglo 
temleni'V in a matter of Utile ditSeiilty. Tlie history of n?poated bleedings 
tlK' habitual Appearance of bruises upon slight injury', and the affection of 
tlte Jointa, famiiih sufficient eridenc^e of the esistiniice of thin coiiBtitutional 

S>-rii!iarity. In casM whera the t^^ndenr^ in present in a lew degreo the 
ingno«u« is not so etisy. H4!peat«d epiKtaxiii in oft^in tioon in etiUdreo 
wboae health in other reepoct^ is perfectly nrntinburtoTj : qikI the occurreneo 
of spontancouH htemorrliage from this Boiirco in then-fore of no value in 
«BlablifthiR(i tlie exiHtence uf h:emophiiia. A;^ti, profuKe mid even fatal 
" Ht from th« utomaoh and bowels may be met wiih iu new-born in- 
ita. The cnuse of hwniorrhago iu the tietrly-horu is often ub«ciiro ; nnd 
in the abseucK of any evident reason for its ooeurrene^ i4ome obttervera 
have attributeil it to a imecini hittnorrhar^ic tendenry existing' in thu in- 
fniit. This mxy tie »o ; hut the casen ditTer from hmiiiophiliti in tlie fact 
that where lifo is iM-P»erve«l no npecial proneuens to bleeding ij* inanirMted 
after years («oe page 6S5). 80, also, in htL-niorrhagie i>uppiim ]»rofn«o 
friending jjay occur from all the muc^ous surfucca and into tlic ti«<ite« ; hut 
tlie disposition ta bleetl in hero, ubso, a temporary inlirmity which {MlHsea 
off and 18 completely rwovei-ed from. 

[n all autea nf true hn-mophilin careful inquiry will dincoTer the exia- 
of a hereditary teudciicy. especially ou the tude of the mother, uud 
in most cRsea a dufpoxitiou on the [mrt of tlie diild liitnaolf to bleed 
jwofnaely upon Mli^llt provocation. 

The nature of the joint affocticu can only bo iliscovci-ed by eBtabli«Iiittg 
the existence of tiin hiemorrfiagie tendeney ; for there in notliing in llie 
character of the- joint tcyiiiptontH to distiuguiiih the swelling from that pnt- 
dnoed hj other caum^^k. 

fVojpu>i«'& — liietnophilia iH a diseaso which ia aocomponied by seriouit 

iger to life. Tlie exliiiii^iuu prciduccd hy rnnated hn'morrlu^ros is tto 

fct that oorapomtively few of tJie piidenta roaoD adult years. Out of one 

hundred and fifty-two lw>yB, the eubjecta of the hieniorrha^c dispomtion, 

'Grandidier found timt only iiiiietf-cn attained the ago of twenty-one, and 

thnt more than half of the number di»l before coiupletiug their seventh 

y«Ar. Dtath twually orcura from